Introduction to Acute Mechanical Circulatory Support
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1 Introduction to Acute Mechanical Circulatory Support 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 The Field of MCS: Robust with Innovation IVADs HVAD Impella CP TH-RVAD CP TH Impella 5.0 RP BiPellas
3 Kirklin et al JHLT : A Major Inflection Point in CV Medicine HM-II BTT NEJM
4 No Definitive RCT Data Support Acute MCS Use for HR-PCI or Cardiogenic Shock Burkhoff : TH vs IABP Thiele : TH vs IABP (Cardiogenic Shock) Seyfarth: ISAR-SHOCK (Impella 2.5 vs IABP) Stretch and Bonde JACC 2014
5 Hemodynamic Efficacy Without Clear Clinical Benefit in Small RCTs Comparing Acute MCS Options Thiele and de Waha et al EHJ 2017
6 Less Use of IABP in Cardiogenic Shock Seyfarth: ISAR-SHOCK Burkhoff: TH vs IABP Thiele: TH vs IABP Patel : CRISP-AMI Thiele: IABP-SHOCK II JAMA 2015
7 Increasing Use of Continuous Flow in Cardiogenic Shock O Neill: PROTECT II (HR-PCI) O Neill: USPELLA AMI/Shock Kar: TandemHeart in CGS Seyfarth: ISAR-SHOCK (Impella 2.5 vs IABP) JAMA 2015
8 Clinical Success with Acute MCS: Less about the tools, More about how and when you use them Kapur and Davila Eur H J 2017
9 Indications for Acute Mechanical Circulatory Support High Risk Intervention 2014 AHA/ACC Guideline for the Management of Patients With Non ST- Elevation Acute Coronary Syndromes. Circulation Revascularization in Heart Failure: Class I Revascularization strategy based on degree, severity, & extent of CAD; cardiac lesions; extent of LV dysfunction; prior revascularization. PVADS: Large amount of ischemic territory/poor LV function 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. JACC High risk patients: Class IIb CLASS III: HARM without Hemodynamic support; for PCI at hospitals without onsite cardiac surgery Cardiogenic Shock* 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. JACC PCI and Cardiogenic Shock: Class I Use of Mechanical Circulatory Support: American Heart Association. Circulation 2012 Acutely decompensated heart failure patients: Class IIa 2013 Int l Society for Heart & Lung Transplantation Guidelines for Mechanical Circulatory Support. Jnl of Heart & Lung Transplantation Temporary mechanical support for patients with multiorgan failure: Class I 2013 ACCF/AHA Guideline for the Management of Heart Failure, JACC Bridge to Recovery or Bridge to Decision for acute, profound hemodynamic compromise: Class IIa 2013 ACCF/AHA Guideline for the Management of ST- Elevation Myocardial Infarction. Circulation STEMI and Cardiogenic Shock: Class IIb STEMI and urgent CABG: Class IIa *Impella is the only FDA-approved AMCS device for CGS
10 Pre-Session Question 1 Which of the following pumps employs a centrifugal flow rotary device? 1. Impella CP 2. Intra-aortic balloon pump 3. Veno-arterial extracorporeal membrane oxygenation 4. Heartmate Percutaneous Heart Pump (PHP)
11 Pre-Session Question 2 Which of the following 2 MCS devices reduce LV preload? 1. Impella CP 2. Intra-aortic balloon pump 3. Veno-arterial extracorporeal membrane oxygenation 4. TandemHeart left sided MCS device
12 Pre-Session Question 3 True or false. VA-ECMO can increase RV afterload? 1. True 2. False
13 Pre-Session Question 4 Which of the following devices can be used in the setting of acute aortic regurgitation? 1. Impella CP 2. Intra-aortic balloon pump 3. Veno-arterial extracorporeal membrane oxygenation 4. TandemHeart left sided MCS device
14 Pre-Session Question 5 Which of the following hemodynamic formulas has NOT been reported to identify severe RV failure in AMI? 1. Right atrial pressure 2. Right atrial:pulmonary capillary wedge pressure ratio 3. Pulmonary pulse pressure/right atrial pressure 4. Pulmonary artery compliance
15 Pre-Session Question 6 Which one of the following components of the LV pressure volume loop consume the most energy? 1. Isovolumic contraction 2. Isovolumic relaxation 3. Early diastolic filling 4. Systolic ejection
16 Pre-Session Question 7 Which one of the following is LEAST likely to improve North-South Syndrome with VA-ECMO? 1. Optimizing lung oxygenation and ventilation 2. VVA-ECMO 3. VAV-ECMO 4. VA-ECMO + Impella CP (ECPELLA)
17 Pre-Session Question 8 Which of the following configurations can be used for biventricular failure and shock in the setting of an LV thrombus? 1. Biventricular Impellas 2. VA-ECMO + Impella CP 3. VA-ECMO alone 4. VA-ECMO + LA venting
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