MANAGEMENT OF CARDIOGENIC SHOCK
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1 MANAGEMENT OF CARDIOGENIC SHOCK
2 CASE PRESENTATION 37 year old Dutch female No known coronary artery disease risk factors 1 week post partum at time of presentation (G3P3) after an uncomplicated normal delivery Sudden onset of severe retrosternal chest pain at 0115 hours Arrived at Emergency Department 0134 hours
3 CASE - ECG
4 CASE - CXR
5 CASE - PROGRESS Diagnosed acute anterolateral ST elevation MI and Killip Class 2 CVL activated and brought for primary PCI Arrived in CVL 0143 hours Vital signs: BP 104/76, HR 94/min, SpO2 98%
6 CASE - CORONARY ANGIOGRAM Left Main Occlusion
7 CASE - CORONARY ANGIOGRAM Co-dominant RCA with no collaterals
8 CASE - PROGRESS Diagnosed acute anterolateral ST elevation MI and Killip Class 2 CVL activated and brought for primary PCI Arrived in CVL 0143 hours Vital signs: BP 104/76, HR 94/min, SpO2 98% After the initial diagnostic angiogram, the patient became progressively breathless and BP was 80/60 mmhg and HR 120/min STEMI secondary to peri-partum left main dissection with cardiogenic shock
9 SHOCK: CLASSIFICATION Shock is a state of acute circulatory failure leading to inadequate tissue perfusion and resulted in end organ injury The simplest way to classify shock is: Pump failure cardiogenic shock Tubing malfunction- distributive shock- sepsis, anaphylaxis, spinal shock Fluid loss hypovolemic shock Cardiogenic shock is when the heart is unable to supply enough blood to the body; the primary problem is within the heart itself
10 CARDIOGENIC SHOCK: DEFINITION Evidence of hypoperfusion: cold clammy skin; impaired mentation, oliguria 1. Cardiac index < 1.8 l/min/m 2 2. Systolic BP < 90 mmhg 3. PAWP > 20 mmhg 4. Urine output < 0.5 ml/kg/hr 5. Systemic vasc resistance > 2000 dynes-sec/ cm 5 The failure to define cardiogenic shock consistently or to confirm hemodynamically the presence of elevated PAWP and low cardiac index have confused the clinician and confounded the literature
11 CARDIOGENIC SHOCK: ETIOLOGY AMI with subsequent LV dysfunction remains the most common cause of cardiogenic shock
12 CARDIOGENIC SHOCK: INCIDENCE AND TIMING IN AMI
13 CARDIOGENIC SHOCK: PROGNOSIS Babaer et al JAMA 2005;1294:448
14 CARDIOGENIC SHOCK: PATHOPHYSIOLOGY
15 CARDIOGENIC SHOCK: PATHOPHYSIOLOGY Cardiogenic Shock Spiral Thiele et al EHJ 2010;31:
16 CARDIOGENIC SHOCK: PATHOPHYSIOLOGY Stunned myocardium Infarcted myocardium
17 MANAGEMENT OF CARDIOGENIC SHOCK Specific measures Vasopressors/Ino-dilators Reperfusion Therapy Thrombolysis PCI CABG Intra-Aortic Balloon Pump (IABP) Extra-Corporal Membrane Oxygenation (ECMO) Ventricular Assist Device (Impella, Tandem Heart, LVAD)
18 CARDIOGENIC SHOCK: SPECIFIC MEASURES & VASOPRESSORS 1. Maximize volume (RAP mm Hg, PAWP mm Hg) 2. Maximize oxygenation (e.g., ventilator) 3. Correct electrolyte and acid-base imbalances 4. Control rhythm (e.g., pacemaker, cardioversion) 5. Sympathomimetic amines (e.g., dobutamine, dopamine, norepinephrine) 6. Phosphodiesterase inhibitors (e.g., milrinone) 7. Calcium sensitizer (e.g. levosimendan)
19 COMMONLY USED VASOPRESSOR AGENTS Agent Dose Cardiac Peripheral Vascular Heart rate Contractility Vasoconstriction Vasodilation Dopaminergic Dopamine 1-4 mcg/kg/min mcg/kg/min Dobutamine mcg/kg/min Noradrenaline 2-20 mcg/min Isoprenaline 1-5 mcg/min *vasodilation in renal, mesenteric, coronary, and cerebral vascular beds
20 INO-DILATORS Phosphodiesterase III inhibitors (PDIs), e.g. milrinone are inotropic agents with vasodilating properties The mechanism of action of PDIs is increasing intracellular camp levels by prevention of its breakdown The hemodynamic properties: Positive inotropic effect on the myocardium Peripheral vasodilation (decreased afterload) Reduction in pulmonary vascular resistance (decreased preload) Levosimendan acts by increasing the sensitivity of the cardiac myofilament to calcium A potent inotrope and also a vasodilator of the arterial, venous, and coronary circulation Should be used with caution as it can cause hypotension
21 SHOCK TRIAL: REVASC IN CARDIOGENIC SHOCK
22 SHOCK TRIAL: RESULTS Hochman et al. JAMA 2001;285:190-2
23 CARDIOGENIC SHOCK: PERCUTANEOUS VENTRICULAR ASSIST DEVICES (VAD)
24 CASE - IABP INSERTION Started on dopamine infusion Patient became restless with drop in O2 saturation and was subsequently mechanical ventilated Left femoral artery puncture with intra-aortic balloon pump (IABP) insertion after diagnostic angiogram Cardiac surgeon was called After discussion with surgeon, advised to proceed with PCI
25 IABP: MECHANISM OF ACTION Inflation (Diastole) Augmentation of diastolic pressure Increase coronary perfusion Increase myocardial O2 supply Deflation (Systole) Decrease cardiac work Decrease afterload Increase cardiac output
26 IABP: META-ANALYSIS IN STEMI WITH CS Sjauw et al. Eur Heart J. 2009; 30(4):
27 IABP-SHOCK II TRIAL
28 IABP-SHOCK II: TRIAL FLOW AND TREATMENT
29 IABP SHOCK II: RESULTS IAPB had no impact on: day mortality (39.7% IABP vs. 42.3% control, p=0.92) independent of STEMI/NSTEMI 2. Renal function, serum lactate (microcirculation) and CRP increase (inflammatory) Thiele et al. NEJM 2012;367:
30 ISSUES WITH IABP SHOCK II Cross over of 10% More frequent use of LVAD devices (7.4 vs. 3.7%) More than 80% of IABP were insert after the PCI Inclusion criteria: No hemodynamic measurements Too strict? Too lenient? BP systolic < 90 mmhg for 30 min Required inotropes to maintain BP above 90 mmhg Signs of pulmonary congestion Signs of organ failure
31 CASE LAD AND LCX WIRING
32 CASE - LM/LAD STENTING BMS 4.5 x 32mm to LM/LAD
33 CASE - POST LAD STENTING BP 69/50, HR 182/min SpO2 96%
34 LCX STENTING
35 CASE - POST LCX STENTING
36 CASE - FINAL ANGIOGRAM BP 60/39, HR 160/min, SpO2 97%
37 PERCUTANEOUS VAD
38 TANDEMHEART CARDIAC ASSIST TECHNOLOGY
39 TANDEMHEART CENTRIFUGAL PUMP
40
41 TANDEM HEART IN CARDIOGENIC SHOCK
42
43 TANDEMHEART VS. IABP RANDOMIZED TRIAL IN CARDIOGENIC SHOCK Burkhoff et al. AHJ 2006;152:469
44 IMPELLA ABIOMED LP LD
45 IMPELLA AXIAL-FLOW PUMP
46 IABP=13 Impella LP 2.5 =12
47 46% both groups
48 IABP VS. PERCUTANEOUS VAD META-ANALYSIS - MORTALITY Kaplan-Meier curve for an individual patient based on a metaanalysis of the 3 randomized studies comparing percutaneous left ventricular assist devices (LVAD) versus intra-aortic balloon pump therapy
49 COMPLICATIONS OF LV SUPPORT DEVICES
50 META-ANALYSIS OF THERAPY IN CARDIOGENIC SHOCK
51 CARDIOGENIC SHOCK: PATHOPHYSIOLOGY Cardiogenic Shock Spiral Thiele et al EHJ 2010;31:
52 CARDIOGENIC SHOCK: PATHOPHYSIOLOGY Cardiogenic Shock Spiral Thiele et al EHJ 2010;31:
53 ESC 2010 GUIDELINES ON MYOCARDIAL REVASCULARIZATION
54 CASE - ECMO INSERTION
55 DEFINITION FOR ECLS Short term devices of simplified Heart and/or Lung Bypass circuit Extracorporeal Membrane Oxygenation (ECMO) with veno-venous (VV) extracorporeal oxygenation for respiratory function substitution Extracorporeal life support technique (ECLS) with a veno-arterial (VA) circulation for both oxygenation and hemodynamic assistance Now more commonly used ECMO
56 VA ECMO Consists of: Cannulae Circuit tubing Centrifugal pump Oxygenator Heat exchanger All specially coated to reduce the risk of clot formation
57 N=27
58 N=81
59 N=21
60 N=33
61 N=134
62
63 CARDIOHELP SYSTEM MAQUET
64 LIFEBRIDGE B2T MEDIZINTECHNIK GMBH
65 CAPIOX EBS SYSTEM TERUMO
66 GUIDELINES ON MYOCARDIAL REVASCULARIZATION
67 NHCS EMCO EXPERIENCE PATIENTS AND INDICATIONS Number of patients supported on ECMO over the years: ECMO PATIENTS ECMO PATIENTS Cardiac: 58% ECPR: 28% Respiratory: 19% Others: 5% Main indication for post cardiotomy ECMO support: low cardiac output syndrome and/or ventricular arrhythmia Main indication for cardiogenic shock/ecpr ECMO support: acute myocardial infarct Steady increase in VV support for respiratory failure in the last few years
68 68
69 CASE - ECG POST PCI
70 CASE - TTE POST PCI
71 CASE - PROGRESS POST PCI No improvement of LVEF after PCI and remained in cardiogenic shock Unable to wean off ECMO Decision made for implantation of LVAD device as bridge to transplant HeartMate II LVAD was implanted D10 of admission
72 ESC 2010 GUIDELINES ON MYOCARDIAL REVASCULARIZATION
73 CASE - LVAD IMPLANTED
74 CASE - PROGRESS POST PCI Extubated 2 days post LVAD implantation No requirement for inotropic support Discharged and flown back to Holland 6 weeks post admission for heart transplant consideration
75
76 CASE PROGRESS 2 YEARS POST LVAD IMPLANTATION Doing well with LVAD Taken off transplant list No immediate plans for cardiac transplantation
77 52% 25% 8% 23%
78 HeartMate XVE vs HeartMate II
79 58% 24% RR % CI P = 0.008
80 1 st gen pulsatile LVAD (Thoratec and Heartmate xve) 2 nd gen CF LVAD HeartMate II 3 rd gen CF LVAD HeartWare HVAD
81 HEARTMATE III
82 NHCS EXPERIENCE: CONTINUOUS-FLOW LVAD Total = 67 patients HM3 HVAD HMII
83 NHCS EXPERIENCE: CONTINUOUS-FLOW LVAD 5/09 TO 12/15 48 HeartMate II, 18 HVAD & 1 HM3 14 as Destination Therapy 53 Males & 14 Females Median age 50 years (14 70 years) Diagnosis (n=67): DCMP (29) Ischemic CMP (24) Chemo-induced (3) Viral (2) ACS (9) Crash & burn : 18
84 NHCS EXPERIENCE: CONTINUOUS-FLOW LVAD 5/09 TO 12/15 All discharged home with device except for 3 perioperative mortality ICU: 3 to 101 days Median 7 days Hospital Stay: 13 to 114 days Median 32 days Mean duration of support 722 days (1.98yrs) Longest support 2431 days (6.6yrs) Total follow-up period patient years
85 NHCS EXPERIENCE: CONTINUOUS-FLOW LVAD 5/09 TO 12/ bridged to transplant (20%) 1 transferred to country of origin for further follow up (1.5%) 1 bridged to recovery (1.5%) 9 mortality (13%): 3 peri-operative (4.5%) 43 on-going support (64%) - 22 on waitlist, 11 DT, 2 refused transplant, 8 recovering from recent surgery & need reassessment for Heart Transplant eligibility (at least 3 mths s/p LVAD)
86 NHCS EXPERIENCE: HEART TRANSPLANT PROGRAM First heart transplant: 6 Jul heart transplants (3 redo heart transplants) Sex: Male = 49, Female =14 Age: 14 to 65 years (mean age 46) Indications
87 NHCS HEART TRANSPLANT: NUMBER OF PATIENTS/YEAR HOTA amendment in July 2004 to include beyond kidneys, to heart, liver & cornea
88 NHCS HEART TRANSPLANT: SURVIVAL RATE Local Data ISHLT (2013) 1 Year 78.2% 85.7% 5 year 66.1% 72.1% 10 years 56.4% 56.1%
89 WAITING LIST 23 Patients waiting time days (mean 757) 22 on LVAD support, 4 Female Age years (mean 45) Support duration range days (median 995) 1 non-lvad support 16 yo with possible chemo induced DCMP Issues with heart transplant Lack of donor Asian culture and religions Cost insurance or government funding Strict selection criteria young, minimal comorbidities etc Long term immunosuppression infection, maglinancy
90 CAUSES OF DEATH AFTER TRANSPLANT 4 major causes: Acute allograft rejection Infections other than cytomegalovirus (CMV); CMV infection was responsible for less than 1 percent of deaths in the ISHLT registry Allograft vasculopathy Lymphoma and other malignancies First 30 days: Graft failure (primary and non-specific) 40%of deaths Multiple organ failure - 14% Non-CMV infection - 13% Between 31 days and one year: Non-CMV infection - 33% Graft failure (primary and non-specific) - 18% Acute rejection - 12 percent After 5 years: Allograft vasculopathy and late graft failure - 30% Malignancies 22% Non-CMV infection 10%
91 TREATMENT OF CS IS PREVENTION! Reduction of CS during hospitalization with increase rate of PCI Jeger et al. Ann Intern Med 2008;149:618-28
92 AMIS (SWITZERLAND) PLUS REGISTRY Cardiogenic Shock in ACS Patients, P Value Overall 12.9% 5.5% Shock Developing In-Hospital 10.6% 2.7% Mortality from Cardiogenic Shock in ACS Patients, P Value Overall Mortality from Shock 62.8% 47.7% Mortality from Shock Developing In- Hospital 73.8% 46.6% Mortality from Shock on Admission 60.9% 48.9% 0.094
93 In-hospital mortality TREATMENT OF CS IS PREVENTION! Reduction in mortality with early PCI Zeymer et al ESC Congress 2009
94 CONCLUSION Cardiogenic shock is associated with extremely poor prognosis and early revascularization improve prognosis as compared to initial medical care Severe LV dysfunction post STEMI may be due to stunning and mechanical support with VADs can bridge the heart to functional recovery However, current VAD (IABP, TandemHeart, Impella ) have not been shown to improve survival in clinical trials Use of VA-ECMO has been successful in many case series in patients with refractory cardiogenic shock but never been tested in clinical trial Selection of patients and devices for mechanical support is important because of complications, cost and futility Early PCI in STEMI may reduce incidence of cardiogenic shock
95 THANK YOU!
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