Epidemiology of Heart Failure in Adults

Transcription

1 Cardiac Critical Care : Focused on IABP & PCPS

2 Epidemiology of Heart Failure in Adults Prevalence Incidence Mortality 2004 Hospital Cost Age 20+ (New Cases) All Ages Discharges Age All Ages 5,200,000 (2.5%) 550,000 57,700 * 1,099,000 $ 33.2 billion (AHA, Heart Disease and Stroke Statistics 2007 Update. Circulation 2007) * F 1994 t 2004 d th f HF i d 28% I * From 1994 to 2004, deaths from HF increased 28%. In the same time period, the death rate declined 2.0%

3 In-hospital mortality in the EuroHeart Failure Survey II by history of heart failure Crit Care Med 2008; 36[Suppl.]:S3 S8

4 Cardiogenic shock with AMI : 2.4 to 12% with a mortality as high as 75% Goldberg RJ N Engl J Med 1991 The need for circulatory support in the postcardiotomy period : 0.2 to 0.6% Torchiana DF J Thorac Cardiovasc Surg 1997 The goal of temporary assist devices is to achieve improved function of the native heart, allowing for removal of the device

5 Direct Circulatory Support Extracorporeal Life support: Centrifugal Pumps, Short term Extracorporeal membrane oxygenator (ECMO) Percutaneous Cardiopulmonary Support (PCPS) Ventricular assist devices: Pulsatile/Axial pump, long term

6 Determinants of cardiac performance Preload Afterload Tissue perfusion Contractility O Organ Heart rate dysfunction

7 Treatment of Heart Failure Direct Circulatory Support Preload Afterload Contractility Heart rate IABP ECLS (PCPS) VAD

8 Intra-aortic balloon during systole & diastole Inflation : Augmentation At arterial dicrotic notch Augmentation in proximal aortic diastolic pressure Improved coronary artery flow Aortic pressure LV pressure Dicrotic notch Systolic unloading Presystolic dip Diastolic Augmentation Deflation : Unloading Just before the onset of the next ventricular systole Isovolumetric Contraction period Isovolumetric Contraction period

9 History 1953 Kantrowitz : The concept of increasing coronary blood flow by retarding the systolic pulse pressure 1961 Clauss: external counterpulsation ti system 1962 Moulopoulos, Topaz, and Kolff : inflatable latex balloon inserted into the descending thoracic aorta 1968 Kantrowitz : 1 st case report: postinfarction cardiogenic shock refractory to medical therapy using an IABP

10 Coronary blood flow, aortic & LV wave pressure wave form

11 IABP

12 IABP

13 Physiology

14 Indication Cardiogenic shock, uncontrolled myocardial ischemic pain, postcardiotomy low cardiac output High-risk (High-grade grade Left main CAOD/ 3VD) or failed PTCA Poorly controlled ventricular arrhythmias before or after operation Postinfarction VSD or acute MR after MI

15 IABP contraindication Severe AR Aortic dissection Severe aortoiliac or iliofemoral disease Abdominal or descending thoracic aneurysm BRAUNWALD S HEART DISEASE 7 TH EDITION 2005

16 Complication 12.9 and 29% and average 20% Leg ischemia: 9 to 25% Infection at the insertion site: 2~3% Balloon rupture: 1.7% false aneurysm formation: 1% Septicemia: 1% Aortoiliac perforation Thrombosis within the balloon bleeding, lymph fistula, lymphocele, and femoral neuropathy, aortic dissection

17 IABP & Mortality

18 ECMO vs. PCPS (Extracorporeal ECMO orporeal Membrane Oxygenation) Therapeutic method using extracorporeal circulation mainly to support respiratory function of the lung while waiting for the lung to recover. vs. PCPS (Percutaneous Extracorporeal Cardiopulmonary Support ) Closed cardiopulmonary bypass system with a centrifugal pump and a membrane oxygenator while its cannulation sites are the femoral artery and vein.

19 What is ECMO/PCPS? Oxygenation outside the body Support heart and/or lung function Similar to bypass used in the operating room but can be used for longer periods of time

20 How ECMO/PCPS Works? Pumping blood out of the body O 2 is added to the blood and CO 2 is removed before it is returned to the patient Pumping a steady amount of blood into the body through the machine each minute : the ECMO flow rate As the patient improves, we may decrease the flow rate and let their heart and lungs do more of the work

21 Percutaneous Cardiopulmonary Support Difficulty in weaning from CPB during open heart surgery Inadequate cardiopulmonary support even after IABP Low blood pressure below 80 mmhg under full support by catecholamines Oliguria/anuria (<1ml/kg/h) Low cardiac output (<1.8 l/min/m2) Low PaO2 (<60mmHg) Uncontrollable VF/VT Uncontrollable metabolic acidosis Sawa Y.J Artif Organs 2005;8:

22 The History of PCPS 1961 The first case of mechanical cardiac support 1969 Commercialization of membrane oxygenator 1972 The first case of ECMO 1975 Commercialization of centrifugal blood pump 1976 The first case of CPR with a portable CPB device 1983 The first case of PCPS by Philips et al 1988 The first case of PCPS supported PTCA by Vogel et al 1994 Listed as medical device can be reimbursed

23 Historical Backgrounds Since the first PTCA performed by Andreas Gruentzig in 1977, abrupt closure and restenosis were major limitation of PTCA Abrupt closure emergent bypass surgery (mortality as high as 12%!!!) Patients with high risk of hemodynamic collapse after abrupt closure may not survive long enough to undergo emergent bypass surgery or may not tolerate even transient ischemia during balloon inflation Need for improved methods of circulatory support Hence, femoro-femoral bypass support was introduced in high-risk patients undergoing PTCA Shawl F.A Am Heart J 1990

24 Purpose of Mechanical Circulatory Support Bridge to transplant Bridge to recovery Destination therapy

25 Concepts of conventional ECMO from Cardiopulmonary Bypass Bleeding Infection d/t open circuit Difficult to setting Need for perfusionists

26 Percutaneous Cardio-pulmonary Support Oxygenator Quick Compact Simple Safe Pump CAPIOX Emergency Bypass System (EBS), Terumo

27 PCPS Sawa Y.J Artif Organs 2005;8:

28 Indications for PCPS-1 Cardiac failure, Acute circulatory failure Respiratory arrest, Acute respiratory failure (Asthma, ARDS, pulmonary embolism) Myocarditis, Cardiomyopathy PTCA support Emergent PTCA with IABP ineffectual PTCA failure, Elective PTCA (e.g. LM/multivessel disease)

29 Indications for PCPS-2 Post operative circulatory support Low cardiac Output Syndrome (LOS; post open heart surgery) Supporting method for surgery Cardiovascular surgery (replacement of descending aorta) Respiratory surgery Poisoning, i Arrhythmia h

30 Standards for the Introduction of PCPS 1. Severe cardiac rhythm failure (frequent ventricular tachycardia, fibrillation and cardiac arrest) 2. Severe cardiac failure cases satisfy the following conditions along with drug therapy and IABP 1) C.I. < L/min/m 2 2) Systemic blood pressure < 80 mmhg (under full support by catecholamine) 3) LA/PCWP pressure or RA pressure > 20 mmhg 4) urine volume < 20ml/hr 5) metabolic acidosis 6) PO PaO 2 60mmHg

31 Contraindications for PCPS Trauma with excess hemorrhage DIC Cardiac arrest without t a witness Ethical problems End-stage cancer

32 Complication of PCPS Bleeding Renal failure DIC Thrombosis Hemolysis Ischemia of the lower extremities Sawa Y.J Artif Organs 2005;8:

33 Structure of PCPS Console oo oooo Pump Drive motor Oxygenator Flow sensor Gas F.A. Heater Priming Controller F.V.

34 Flow sensor Gas Console Priming Continuous and reverse perfusion with a closed circuit Enables quick set up of circuit with easy cannulation Effective perfusion to organs Cannot support heart function due to after-load

35 Concepts of EBS Compact Priming volume (470ml) Light weight (14 kg) Quick Pre-connected Safe Internal battery Less hemolysis Auto-priming mode Lock connector

36 EBS auto priming Blood in Gas in Priming solution Blood out Oxygenator Gas out Air Within few minutes, deairing is completed in EBS using auto-priming system.

37 Specifications Max. pump speed: 3000 rpm Max. flow rate: 8 L/min Max. pressure: 800 mm Hg Priming volume: 470(45) ml Port size: 3/8 inches

38 18F cannula sheath inserted in femoral artery 21F catheter placed in right atrium

39

40

41 Ventilator settings Neonates and Infants : Reduce gradually to FiO ( ) over 1-2 hours if possible Peak airway pressures 20 cm H 2 O Rate: 10/min PEEP: 4cm H 2 O Pediatrics and adults : FiO Peak airway pressure 20 30cm H 2 O Rate: /min PEEP 10cm H 2 O

42 Immediately after start-up Chest X-ray Labs: CBC, ABGs, eletrolyte, total protein, albumin, glucose, ACT - q 4hrs: Hgb, Hct, platlets, Na, K, glucose - q 1hr and prn, q 2hrs when stable : ACT, ABGs Daily : CBC, CRP,Na, K, Cl, Ca and ion. Ca, P, Mg, BUN, creatinine, total protein, albumen, glc, bilirubin, SGOT, SGPT, LDH, amylase, coagulation status including ATIII U/A, CXR Ultrasound of head (neonates) Microbiology: urine, sputum. Blood cultures

43 Medications Pain medication Antibiotics prophylaxis Dopamine, Dobutamine, milrinone etc. TPN or enteral nutrition when possible Heparin - Initial dose 100 IU heparin / kg iv maintain with IU/kg/hr using infusion pump recommend ACT between 180 and 200 seconds - If ACT < 150 seconds give immediately 50IU heparin/kg bolus IV (15 25 IU for neonates and children) Then adjust infusion rate

44 Weaning from PCPS It is recommended to change the tube and rinse the airways before weaning from PCPS The ECMO flow is then reduced by 60-70% during hours Reduce the sweep gas to the oxygenator reduce FiO 2 till 0.21 Increase the ventilator support to satisfactory O 2

45 Trial off PCPS The PCPS support is stopped for a limited period of time to assess the patients ability to oxygenate and remove CO2 and maintain hemodynamics under drug therapy Arterial and venous tubing is then clamped, the PCPS-system is kept ready and recirculated to avoid coagulation of the system if it is needed to reestablish support

46 Clinical trials evaluating ECMO for the treatment t t of postcardiotomy t cardiogenic shok Patients (no.) Duration of support Weaned from Survived to hospital (range) device, no. (%) discharge, no. (%) Magovern h 16 (76) 1 (52) Wang h 10 (55) 6 (33) Muehrcke h 9 (39) 7 (30) Magovern h 36 (65) 20 (36)

47 Outcome of the Perioperative Use of PCPS for Adult Cardiac Surgery: Factors Affecting Hospital Mortality (ml) Odds ratio p-value PCPS flow (initial) PCPS running time>48hr UV < 2000mL/day Age > 70 years Artif Organs, Vol. 28, No. 2, 2004 :

48 Problems and Limitations Circulatory Support good enough Ventricular Assist No Long term Support insufficient Acute Onset suitable Organ Perfusion insufficient Inflammatory Response problematic

49 Institutional Experience ~ N=50 (2006:18, 2007:32) M:F=30:20 Age : 17 days ~ 92 years (mean: 60.3 years) PCPS insertion during CPR: 16 (32%) Dual support with IABP: 9 (18%) PCPS support time: 20min ~ 19.1 days (2.7 d) Overall mortality: 24 (48%)

50 % 55.0% 75.0% 66.7% %

51 Summary PCPS is widely spreading in the cardiology and cardiovascular surgery fields and also in ICU and as a supportive method for open heart surgery with new devices such as femoral cannulation. The clinical outcomes of the PCPS is improving year by year, however, there are many complications and devices should be improved further.

52 Summary Also, further discussion ssion is needed about the applications, duration of circulatory support and ethical concerns. Further improvement of PCPS is expected due to discussion of the issues and device developments in the future.