DECLARATION OF CONFLICT OF INTEREST

Transcription

1 DECLARATION OF CONFLICT OF INTEREST

2 Cardiogenic Shock Mechanical Support Eulàlia Roig FESC Heart Failure and HT Unit Hospital Sant Pau - UAB Barcelona. Spain

3 No conflics of interest

4 Mechanical Circulatory Support Left / right ventricular dysfunction Cardiogenic shock iv inotropics Low CO Peripheral hypoperfusion STEMI - PCI Acute myocarditis Acute valve disease Postcardiotomy Sustained hypotension (SBP < 90 mmhg) H Thiele Eur Heart J 2007;28:2057 A Mebazaa Crit Care Med 2008;36:120 Low cardiac index < 2 l/min.m 2 PCWP > 18 mmhg Clinical evidence end-organ hypoperfusion: oliguria increased lactate levels severe peripheral hypoperfusion (cool and clammy skin) alteration mental status MCS

5 Cardiogenic shock Mechanical Circulatory Support The most well known and oldest MCS is the Intra-aortic balloon pump (IABP) Percutaneous assist devices Surgical assist devices Clinical evidence of its impact on improving the pt s condition

6 IntraAortic Balloon Pump (IABP) Current expert guidelines for STEMI complicated with cardiogenic shock support IABP counterpulsation as the method of choice for mechanical assistance IABP beneficial effects Easy to implant Improves coronary perfusion myocardial oxygen supply After-load reduction Improves distal perfusion / B Reduction of myocardial work Improvement LV performance (CO 1,5 L/min) F Van der Werf Eur Heart J 2008;29:2909 EM Antman J Am Coll Cardiol 2004;44:761 H Thiele Eur Heart J 2007;28:2057 HR Reynolds Circulation 2008;117:686

7 Meta-analysis of IABP therapy in STEMI and CS National Registry of AMI-2 and CS (23,180) IABP implanted in 31% of pts. Non-randomized studies IABP may have been preferentially given to patients in worse condition Reflect a longer ischemic time if it was implanted for transfer the patient The results of this meta-analysis must be interpreted with caution KD Sjauw Eur Heart J 2009;30:459 HV Barron Am Heart J 2001;141:933

8 IABP SHOCK Trial in STEMI and CS 40 pts were randomized before coronary angiopgraphy and PCI 19 to IABP and 21 standard therapy without IABP Primary endpoint was a change in APACHE II score (Acute Physiology And Chronic Health Evaluation), cardiac index, BNP, IL-6 levels within 4 days Mortality was 32% in IABP vs 24% in MT P<0.05 Due to the low number of pts included, the study was not powered to analyze survival New randomized studies with mortality as the primary endpoint are needed in these patients Ongoing trials: IABP Shock-II and RECOVER II R Prondzinsky Crit Care Med 2010;38:152

9 Data from the SHOCK Trial - STEMI and CS H Thiele Eur Heart J 2007;28:2057 S Unverzagt Cochrane Databse Sys Rev 2011 K Ramanathan Am Heart J 2011;162:268 S Topalian Crit Care Med 2008;36:S66 Randomized trial comparing ERV with PCI vs MT 185 patients with STEMI and CS were treated with IABP Rapid complete reverse of hypoperfusion (CRH) 30 min after IABP implantation was achieved in 68 pts (37%) 75% 37% 30-day mortality: 25% CRH vs 63% non CRH, (p<0,001) after adjusment for age, LVEF and early revascularization Need for continuous evaluation and if hemodynamic improvement is not achieved at 4-6 hours the implantation of an assist device should be considered

10 Cardiogenic shock Mechanical Circulatory Support Intra-aortic balloon pump Percutaneous assist devices Surgical assist devices Clinical evidence of its impact on improving the pt s condition

11 Acute cardiogenic shock Left / right ventricular dysfunction iv inotropics IABP AMI - PCI Acute myocarditis Acute valve disease Postcardotomy Pts surviving a CA Severe CS at admission Low CO with Peripheral hypoperfusion LVAD Clinical endpoint Early hemodynamic stabilization Increase CO Unload of the left ventricle Reduction of end-organ failure Improve survival H Thiele Eur Heart J 2007;28:2057 K Ramannathan Am Heart J 2011;162:268 S Topalian Crit Care Med 2008;36:S66 M Slaughter J Heart Lung Transplant 2010;29:51

12 Percutaneous MCS Impella microaxial flow pump TandemHeart TM centrifugal pump H Thiele Eur Heart J 2007;28:2057

13 ECMO: extracorporeal membrane oxygenation External blood pump connected to a membrane oxygenator similar to the cardiopulmonary bypass system used in cardiac surgery Short duration (< 1 month) Surgical MCS CS associated with severe respiratory insufficiency Continuous flow assist device Levitronix Rotary blood pump providing continuous flow Easy to implant, external CO 10 L/min, uni or bivad Duration 1 month Pulsatile flow assist device Pneumatic sac-type pump provides pulsatile flow External CO 10 L/min, uni or bivad Longer duration > 1 year Excor Berlin Heart M Slaughter J Heart Lung Transplant 2010;29:51

14 Surgical MCS Patients on CS are too sick for permanent LVAD. Therefore stabilization using a temporary system is considered the best option In some patients in whom recovery of ventricular function is not expected a long-term VAD can be implanted BiVAD should be considered if there is right ventricular dysfunction VAD should be implanted before irreversible multi-organ failure is present LW Stevenson J Heart Lung Transplant 2009 M Slaughter J Heart Lung Transplant 2010 Kirklin JK JHLT 2011;30:115

15 Patient stabilized with MCS Bridge to Recovery AMI + stunning myocardium Fulminant myocarditis Postcardiotomy Bridge to Heart Transplantation No contraindications for HT Non-revascularized AMI Chronic ischemic and non-icm M Slaughter J Heart Lung Transplant 2010 L Lund Eur J Heart Fail 2010;12:434 Bridge to long term LVAD or Destination therapy

16 Concerns for VAD implantation Severe aortic insufficiency should be corrected with a bioprosthesis Mechanical aortic valve should be replaced with a bioprosthesis Uncertain neurologic status after surviving a cardiac arrest High risk of bleeding (pre-operative abnormal coagulation) Severe thrombocytopenia (Heparin-induced antibodies) Active sepsis Advanced inflammatory systemic response syndrome (SIRS) Correct evaluation of irreversible end-organ failure is still a challenge Advanced age or severe comorbidities may contraindicate VAD L Lund Eur J Heart Fail 2010;12:434 M Slaughter J Heart Lung Transplant 2010;29:51 JL Brown Current Treat Options Cardiovasc Med 2011 S Topalian Crit Care Med 2008;36:S66

17 Cardiogenic shock Mechanical Circulatory Support Intra-aortic balloon pump Percutaneous assist devices Surgical assist devices Clinical evidence of its impact on improving the pt s condition

18 Percutaneous VAD: TandemHeart 117 patients with refractory CS, (48%) underwent CP resuscitacion Hemodynamic and metabolic parameters B Kar JACC 2011;57:688 mortality at 30-day was 40%

19 Randomized trial IABP vs TH 41 AMI and CS IABP 20 pts vs TandemHeart 21 pts 95% of pts underwent primary PCI The primary endpoint was hemodynamic improvement within 2 h after device insertion H Thiele Eur Heart J 2005;26:1276 The median duration of support was not different between the two systems

20 Adverse events comparing IABP and TH IABP VAD-TH p Limb ischemia Transfusions Fresh frozen plasma and platelets Fever IABP mortality 45% 3 HF 1 MODS TH mortality 43% 4 MODS Despite higher hemodynamic stability with TH, 30-day mortality was not reduced H Thiele Eur Heart J 2005;26:1276

21 ISAR-SHOCK trial: Impella LP 2.5 vs. IABP Cardiogenic shock Caused by AMI Randomized trial two centers: 25 pts IABP (13) vs Impella (12) implanted after revascularization therapy The primary endpoint was hemodynamic improvement within 30 min after device insertion The increase in CI was greater with the Impella than IABP +0.49±0.46 vs +0.11±0.31 (p=0.002) Serum lactate were lower 6 patients died in each group M Seyfarth J Am Coll Cardiol 2008;52:1584

22 Meta-analysis IABP vs P-AD 42 pts 42 pts 25 pts Randomized studies Despite higher hemodynamic stabilization with PAD, the higher rate of complications and the presence of more advanced inflammatory syndrome might explain the lack of improvement in 30-day mortality Cheng JM Eur Heart J 2009;30:2108

23 Surgical LVAD / HT Retrospective study of 138 pts with STEMI and cardiogenic shock All treated with inotropics and IABP 43 pts conservative therapy 95 pts aggressive therapy: 77 PCI (47%) or CABG (43%) 5-year mortality 18 (19%) LVAD/HT (ECMO+LVAD 14, 1 LVAD, primary HT 3) In-hospital mortality BTT was successful in 72% W Tayara J Heart Lung Transplant 2006;25:504

24 BiVAD as a bridge to HT in CS Retrospective study of 80 patients, all were in critical CS with emergency implantation of bivad Alive(71%) Death(29%) BTT was successful in 57 pts (71%) 20 pts (87%) died of MODS J Moriguchi J Heart Lung Transplant 2011

25 Conclussions IABP continue to be the first choice of MCS in pts with CS. More studies are needed in pts with an AMI undergoing primary PCI to establish the best approach. Percutaneous VAD achieve faster and higher hemodynamic stability. However, this did not translate into improved 30-day survival Percutaneous or surgical VAD implant should not be delayed in patients without initial stabilization with IABP or presenting with profound CS

26 Conclussions Despite the rapid hemodynamic stabilization achieved with VAD, the high rate of complications or advanced inflammatory syndrome and ongoing multiorgan failure may explain the high mortality How to apply this expensive technology in the real world and how to define when ongoing efforts are futile is still a challenge (J Tallaj JACC 2010) In very selected patients with cardiogenic shock, LVAD can be successfully bridged to HT