HOW TO PERFORM LEFT VENTRICULAR ASSISTANCE IN THE CATHLAB. Andreas Baumbach, MD FESC FRCP Bristol Heart Institute University Hospitals Bristol UK

Transcription

1 HOW TO PERFORM LEFT VENTRICULAR ASSISTANCE IN THE CATHLAB Andreas Baumbach, MD FESC FRCP Bristol Heart Institute University Hospitals Bristol UK

2 Disclosure I have no conflicts of interest regarding this presentation

3 Objectives Identification of available technology Establish evidence based indications Practical review of Technology Placement Management Complications Of Intraaortic counterpulsation

4 How to use LV assistance in the Cathlab CARDIOGENIC SHOCK

5 Monday morning 75 yr old man with anterior STEMI admitted to local DGH Chest pain started 4pm, presented 9:30 Hx of Oesophagus -Ca Transfer for primary PCI 10:15

6 On Arrival BP: 60/40 7 * VF arrest and DC shock

7 EBU 4 BMW wire

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9 Cardiogenic Shock

10 Determinants of Ventricular Function CONTRACTILITY PRELOAD AFTERLOAD STROKE VOLUME - Synergistic LV contraction - LV wall integrity - Valvular competence HEART RATE CARDIAC OUTPUT

11 Management of Acute Ischemic Cardiogenic Shock Inotropic Support Circulatory Support Revascularisation!

12 Circulatory Support: Options Intraaortic Balloon Counterpulsation Left Ventricular Assist Devices Percutanoeous Implantable Total artificial heart Extracorporeal Circulation

13 Intra-Aortic Balloon Pump Inflatable cc balloon Triggered to inflate with helium immediately after aortic valve closure Triggered to deflate with opening of the aortic valve

14 IABP: INDICATIONS

15 Ideal Candidate for IABP Prerequesite for effect of IABP = contractile reserve Without sufficient contractile reserve correction of preload and afterload cannot result in increased stroke volume and cardiac output!

16 IABP Indications Hemodynamic compromise Cardiogenic shock secondary to AMI with continuing ischemia, VSD, or MR Cardiogenic shock due to transient ischemia, myocarditis, sepsis, drug toxicity, etc. Inability to wean from bypass after cardiac surgery Hemodynamic support while awaiting transplantation adapted from Burkhoff D. Grossman s Cardiac Catheterization, Angiography and Intervention 2006, p. 415

17 IABP Indications Medically refractory ischemia Medically refractory unstable angina Failed PTCA with refractory ischemia Severe arrhythmia owing refractory ischemia adapted from Burkhoff D. Grossman s Cardiac Catheterization, Angiography and Intervention 2006, p. 415

18 IABP Contraindications Significant aortic regurgitation Abdominal aortic aneurysm Aortic dissection Uncontrolled septicemia Uncontrolled bleeding diathesis Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgery Bilateral femoral-popliteal bypass grafts for severe peripheral vascular disease adapted from Burkhoff D. Grossman s Cardiac Catheterization, Angiography and Intervention 2006, p. 415

19 LV ASSISTANCE: THE EVIDENCE

20 Assist Devices in STEMI

21 Prophylactic IABP? High-risk PTCA owing to LV dysfunction and/or large territory at risk PTCA during acute myocardial infarction Stabilization in patients with severe aortic stenosis Severe multivessel or left main CAD requiring urgend cardiac or noncardiac surgery Large myocardial infarction adapted from Burkhoff D. Grossman s Cardiac Catheterization, Angiography and Intervention 2006, p. 415

22 CRISP AMI 337 Patients with anterior STEMI NOT in shock IABP vs. no IABP No difference in Infarct size or Microvascular Obstruction CMR Endpoint

23 GUIDELINES

24 ESC GUIDELINES 2010 Acute STEMI

25 Recommendations for Reperfusion Strategies in ST-Segment Elevation Myocardial Infarction Patients ESC Guidelines on Revascularization 2010 Eur Heart J 2010;31: No benefit of IABP in hemodynamic stable patients Increased risk of bleeding and other complications

26 AVAILABLE TECHNOLOGY Courtesy Dr F Eberli, Zurich, EuroPCR 2011

27 IABP Images: Courtesy Datascope

28 Datascope Console Understand the principles!

29 Fluid Filled Systems Pressurized Flushing System Fluid based pressure transmission External pressure transducer Trigger: R-wave of ECG (Aortic pressure) Timing of balloon inflation and deflation according to previous beats Disadvantages: Manual calibration necessary Limited timing accuracy during arrhythmias Pressure Transducer Fluid Filled Tube Images: Courtesy Datascope

30 Fibre Optic Systems Fibre optic manometer in the tip of IAB catheter High fidelity signal transmission at the speed of light Advantages: Artefact free, consistent pressure waves Automatic in vivo calibration High accuracy of automatic timing (arrhythmias!) Smaller catheter size (7F) Images: Courtesy Datascope

31 INTRAAORTIC BALLOON PUMP: HEMODYNAMICS

32 Determinants of Myocardial Oxygen Supply and Demand Supply Demand Coronary Artery Anatomy Diastolic Pressure Diastolic Time Oxygen Extraction Hemoglobin PaO 2 MVO 2 Heart Rate Afterload Preload Contractility

33 Primary Effect of IAB Therapy Supply Demand MVO 2 Supply - IAB Inflation Demand - IAB Deflation

34 Coronary flow IABP Increases Coronary Flow Aortic pressure IABP IABP

35 Intra-Aortic Balloon Pump

36 Intra-Aortic Balloon Pump Decreases Afterload Increases Mean Aortic Pressure Increases Coronary Flow Velocity Reduces Myocardial Oxygen Demand

37 Contractility IABP does not increase contractility of the myocardium. However, the improvement of preload and afterload increases stroke volume and cardiac output.

38 IABP Effects Mean pressure Cardiac output Cerebral perfusion Renal perfusion SVR -> peripheral perfusion

39 Patient With Acute Mitral Insufficiency and Cardiogenic Shock LV = 100/22 mmhg Ao = 100/65/80 mmhg PCWP = a= 25; v= 65; m= 41 mmhg RV = 65/23 mmhg PAP = 65/24/40 mmhg RA = a= 10; v= 9; m= 7 mmhg C.O. = 4.6 L/min. PCWP

40 Decrease of PCWP by IABP in Acute MR IABP off IABP on

41 Effect of IABP in Acute Mitral Insufficiency 100 without 100 with IABP LV ECG LV ECG 50 PCW 50 PCW SEC 1 SEC Decrease of LV Filling Pressure = Decrease of Preload Decrease of Preload Reserve Decrease of Afterload = Decrease of LV Systolic Pressure Grossman s Cardiac Cath 3d edition

42 INTRAAORTIC BALLOON PUMP: INSERTION

43 IABP Catheter: What Size for Which Patient? Manufacturer Balloon Size (mm) Patient Height (cm) (feet) Datascope Corp. 25 <152 < >183 >6 00 Arrow International >183 >6 00 Datascope MEGA 50 ml: Can be used in patients cm Increases blood volume displacment by 25% Courtesy: Datascope

44 The tip of the catheter should be placed at the take of left subclavian artery, i.e. between left main bronchus and aortic knob i.e. between 2 nd and 3 rd rib What is the Correct Position of the IABP Catheter? Too High Ideal Too Low as high as possible in the aorta, but must not touch the roof of the aortic arch After insertion and suturing check correct position by fluoroscopy!!

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46 Non Femoral Access Brachial artery Axilliary/subclavian access Only very small numbers of patients reported

47 INTRAAORTIC BALLOON PUMP: MANAGEMENT

48 IABP: Early Diastolic Inflation Late Diastolic Deflation 120 Increased early diastolic pressure Increased Coronary Flow mm Hg Decreased late diastolic pressure Increased Systolic Function

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50 Reasons for Suboptimal Diastolic Augmentation Intra-aortic balloon remains partly in the sheath is only partly unfolded/inflated is positioned too low in the aorta catheter shaft has a kink is leaking low helium concentration arrhythmias

51 IABP with Fibre Optic System Datascope CS 300 Timing algorithm of new pumps are excellent. Timing of each individual beat possible. ARROW AutoCAT 2 Wave Automatic (machine) timing superior to manual timing by operator. Images: Courtesy Datascope and ARROW

52 Sheath or Sheathless? 1211 pts, retrospective study 305 sheathless/906 sheath Risk factors for limb ischemia: DM and PAD Pts with DM+PAD+sheath: RR 35! -> Sheathless insertion preferred in pts with DM and PAD Erdogan et al, J Card Surg 2006; 21:342

53 Anticoagulation

54 INTRAAORTIC BALLOON PUMP: COMPLICATIONS

55 Complications Event Hematologic Thrombocytopenia Hemolysis Bleeding Thrombo-embolic events Vascular Limb ischemia Aorto-iliac dissection or perforation Mesenteric ischemia Renal failure Infection Management Thrombocytopenia Secondary to platelet destruction Resolves after removal Thrombo-embolic events Prevention by heparin Bleeding Stop heparin up to 24 hours Limb ischemia Check pulses! Bypass of femoral artery Removal of IABP

56 WEANING

57 Weaning Stepwise reduction of counter pulsation Evaluation of spontaneous circulation Removal of balloon 1:1 1:2 1:4

58 IABP PROPHYLACTIC USE OF IABP

59 Case 2 97year old man Previously fit and well (!) NSTEMI with a moderate Troponin rise Moderately impaired LV function No CV risk factors. Apart from smoking No Family history

60 Initial Treatment ASS/ Clopidogrel/Fondaparinux Beta Blocker, ACE I.V. nitrates But recurrent severe chest pain with widespread ECG changes Referral for invasive assessment

61 Angiogram

62 And the left side

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64 Strategy Femoral 8F Heparin 5000U i.v. bolus IABP Insertion: Provisional? Prophylactic?

65 BCIS-1 Study

66 LVEF 30% BCIS-1 Jeopardy Score 8 Elective IABP Insertion Randomize PCI No Planned IABP Remove IABP 4-24 hrs. after PCI Hospital Follow-up To discharge or 28 days 6 month follow-up ONS / GROS Am Heart J 2009;158:

67 Adverse Events (%) BCIS-1: Major Outcomes HR 0.94 ( ) HR 1.86 ( ) HR 0.11 ( ) HR 0.61 ( ) JAMA 2010; 304(8):

68 BCIS-1 Secondary Outcome: 6 month Mortality Routine elective balloon pump insertion before PCI cannot be recommended in patients with severe LV dysfunction and extensive coronary disease 6-month mortality 6.0% (n=300) 30-day mortality 1.3% (n=301)

69 BCIS-1 Follow-up: Results Duration of follow-up (from randomisation): Median 51 months (IQR months) 100 DEATHS (33%)

70 All-cause Mortality by treatment assignment 50% IABP No IABP 40% 30% 20% 10% Hazard ratio 0.66 (95% CI 0.44 to 0.98) 0% IABP No IABP 0 6 m 1 year 2 years 3 years 4 years 5 years Time since randomisation

71 Time-varying Hazard Ratios 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 6 months 0.63 (0.24 to 1.62) < 1 year 0.68 (0.34 to 1.35) > 1 year 0.65 (0.40 to 1.06) p=0.91 for interaction (<1yr vs. >1yr) overall 0.66 (0.40 to 0.98) 0, IABP Better No planned IABP Better

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81 Clinical Course Troponin falling Pain free ECG normalised Patient mobilised on day 1 Patient demands to go home on day 3 Well after 10 days..

82 Outlook

83 Summary IABP is an essential tool for LV support in acute ischaemic cardiogenic shock Knowledge of hemodynamic principles and underlying technology is essential for successful use of IABP The role of LV assist for prevention of complications in high risk interventions has yet to be determined

84 Thank you for your attention

85 Vranx EUROPCR2011

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89 Provisional IABP Elective versus provisional intra-aortic balloon pumping in high-risk percutaneous transluminal coronary angioplasty. Briguori C, Sarais C, Pagnotta P, Airoldi F, Liistro F, Sgura, Spanos V, Carlino M, Montorfano M, Di Mario C, Colombo A. Am Heart J 2003;

90 Provisional IABP for PCI N: 133 patients EF<30% Group A: Preprocedural IABP Group B: Conventional PCI Severe hypotension & shock n:11 in group B Brigouri et al Am Heart J 2003

91 IABP Evidence A prospective randomized evaluation of prophylactic intraaortic balloon counterpulsation in high risk patients with acute MI treated with primary angioplasty Stone et al. J Am Coll Cardiol 1997

92 IABP in primary angioplasty Hypothesis: routine use of IABP after primary PCI reduces infarct related artery reocclusion Multicentre, randomised trial High risk patients randomised to 36 to 48hrs IABP or standard care Stone et al. J Am Coll Cardiol 199

93 IABP in primary angioplasty N:1100 Angio for MI N: 908 randomised N: 437 high risk IABP 211 no IABP 226 Established 86% Crossover 13% Stone et al. J Am Coll Cardiol 199

94 IABP in primary angioplasty IABP no IABP Death Re-MI Reoccl Stroke CHF Endpoint Hypo Stone et al. J Am Coll Cardiol 1997

95 Stone et al. J Am Coll Cardiol 1997 IABP in primary angioplasty Complications No difference in hemorrhagic complications or vascular complications Significant difference in stroke This finding may be due to chance.. One intracranial hemorrhage developed after a postinfarction patient was hit in the head with a shovel while robbing the hospital nursery

96 Benchmark Registry June 96-August Hospitals (90%US) patient case records Verified by external audit Ferguson et al. J Am Coll Cardiol 2001; 38:1456

97 Benchmark Registry: Indication Hemodynamic support during/after catheterisation 20.6% Cardiogenic shock 18.8% Weaning from CP bypass 16.1% Preoperative use in high risk pts 13% Refractory unstable angina 12.3% Ferguson et al. J Am Coll Cardiol 2001; 38:1456

98 Benchmark Registry: Complications Major: Limb ischemia, severe bleeding, balloon leak, death due to IABP 2.6% In hospital mortality 21.2% Failed IABP insertion 2.3% Increased risk for major complications: Women Low BSA Older patients PVD Ferguson et al. J Am Coll Cardiol 2001; 38:1456

99 Correct Timing of Balloon Inflation/Deflation Goal = Maximal diastolic augmentation and decrease in aortic end-diastolic pressure. Inflation: Immediately after aortic valve closure. Early Inflation Deflation: Finished just prior to aortic valve opening. Late Deflation Most serious mitakes: Early inflation/late deflation Balloon interferes with LV ejection Increase in LV afterload and MVO 2 Images: Courtesy Datascope

100 IABP Evidence: SHOCK Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction A report from the SHOCK trial registry Sanborn et al. J Am Coll Cardiol 2000;

101 IABP Evidence: SHOCK Background: National registry of MI suggests lower mortality in pts treated with thrombolysis followed by IABP (49%) compared with thrombolysis alone (69%) GUSTO trend towards better outcome Sanborn et al. J Am Coll Cardiol 2000; 36:112

102 SHOCK Registry N: 856 patients with cardiogenic shock in acute MI 36 participating centres Treatment: No thrombolysis / no IABP 33% IABP only 33% Thrombolysis only 15% Thrombolysis and IABP 19% Sanborn et al. J Am Coll Cardiol 2000; 36:112

103 SHOCK Registry: Mortality Cardiogenic shock (LV Failure) No thrombolysis n=564 64% Thrombolysis n=292 54% p=.005 No IABP n=285 77% IABP n=279 52% No IABP n=132 63% IABP n=160 47% p<.0001 no revasc n=233 83% revasc n=52 48% no revasc n=84 76% revasc n=195 41% no revasc n=105 74% revasc n=27 19% no revasc n=51 69% revasc n=109 37% Sanborn et al. J Am Coll Cardiol 2000; 36:112

104 SHOCK Result IABP vs. no IABP mortality after adjustement for revascularisation p=0.313 Use of IABP with or without thrombolysis improves survival in pts with cardiogenic shock because of the higher rate of attempted revascularisation in the IABP group Sanborn et al. J Am Coll Cardiol 2000; 36:1123