MCS for Acute Heart Failure Eric Adler MD Associate Professor of Medicine Medical Director Cardiac Transplant
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1 MCS for Acute Heart Failure 2016 Eric Adler MD Associate Professor of Medicine Medical Director Cardiac Transplant
2 Why do we decompensate?
3 Which Heart Failure Patients Should Get Palliative Care and Who should get Hospice Allen L A et al. Circulation 2012;125:
4 INTERMACS CLASSIFICATION
5 CARDIOGENIC SHOCK INADEQUATE TISSUE PERFUSION RESULTING FROM CARDIAC DYSFUNCITON IN SETTING OF EUVOLEMIA HEMODYAMIC DEFINITION: SUSTAINED BP <90, CARDIAC INDEX <2.2 AND PCWP >20
6 Incidence of Cardiogenic Shock Growing Cardiogenic Shock in STEMI Increasing 1 STEMI Cardiogenic Shock in Medicare Age Increasing 2 56,508 36,969 53% Dhaval Kolte et al. J Am Heart Assoc 2014 NATIONWIDE INPATIENT SAMPLE 2. Centers for Medicare and Medicaid database, MEDPAR FY14 Age >65 only, excludes non-medicare population
7 HAVING SHOCK IS VERY BAD IABP (n=301) Medical Therapy (n=299)
8 Death Rate, % Mortality % Post Discharge Cardiogenic Shock Remains Leading Cause of Mortality in Acute Myocardial Infarction High In-Hospital Mortality During AMI Cardiogenic Shock 1 and Ongoing Hazard Post Discharge after AMI Cardiogenic Shock 2 N = 23,696 % N = 112, Jeger, et al. Ann Intern Med Shah, et al. JACC 2016 NCDR Registry
9 STAGE D HEART FAILURE Jan 2014 HF symposium Adler.pptx
10 SHOCK PLAN DIAGNOSE IN TIMELY FASHION UNDERSTAND PATHOPHYSIOLGY ACT QUICKLY WORK TOGETHER NO ROOM FOR ERROR
11 Reverse the Cardiogenic Shock Spiral Cardiogenic Shock Identifiers (Protocol elements) SBP <90 mmhg or on Inotropes/Pressors Cold, clammy, tachycardia Lactate elevated >2 mmoi/l Cardiogenic etiology evaluation EKG (STEMI / NSTEMI) Echocardiography If available, PA catheter, Cardiac Output, CPO, CI, PCWP, SvO 2 MAP End Organ Perfusion Cardiac Output Cardiac Power Output Myocardial Recovery Patients Reverse Spiral Ischemia End Organ Failure Progressive Myocardial Dysfunction Death Spiral of Cardiogenic Shock
12 Echocardiographic Findings in Cardiogenic Shock
13 Using the Swan-Ganz catheter to diagnose type of shock
14 ESC Classification Dickstein K, et al. Eur Heart J 2008;29(19):
15 Inotropes: Double Edged Sword Short term benefit Improve cardiac output Decrease left ventricular end diastolic pressure Decrease wedge Short term improvement Also used as palliative and bridge therapy Long Term Risk No long term mortality benefit Increased risk of death have been observed in numerous trials Deaths secondary to both arrhythmia and progressive heart failure Fowler M. Iotropic Therapy A Two-edged Sword. From Heart Failure Management. Martin Duntz Ltd. UK 2000
16 High dose Vasopressors/inotropes Associated With Increased In-Hospital mortality Mortality Risk N = % 42% 2% 3% 7.5% 21% Three High Dose Samuels LE et al, J Card Surg. 1999
17 Oxygen Consumption
18 Myocardial Protection Total energy consumption Reducing PVA 19 Pressure-Volume Area (PVA)= SW x PE Reduced Microvascular Resistance Reduced Energy Consumption SW Increased O 2 Supply Reduced O 2 Demand PE Ventricular Unloading Reduce EDV, EDP Improving Myocardial O 2 Supply / Demand
19 IABP- most common support for CS patients RISK: BENEFIT: Meta-analysis of IABP in ST-elevation MI Sjauw et al., Eur Heart J (2009) IABP associated with only modest reduction in markers of disease severity Prondzinsky et al, Crit Care Med 2010
20 SHOCK 2 TRIAL
21 Hemodynamic Stabilization with Impella Unloads Left Ventricle & Coronary Perfusion End Organ Perfusion Right Side Support Escalation & Ambulation Right Side Impella RP Left Side Impella 2.5/CP/5.0 Seyfarth et al., JACC, 2008 Remmelink M et al., Cath Card Interv Lam K. et al,. Clin Res Cardiol, 2009 Casassus et a., JOIC, 2015 Anderson MB. et al., J Ht Lg Transplant Lima B. et al., Am J Cardiol 2016
22 24
23 Improved Myocardial Perfusion with Impella Coronary Flow Velocity (cm/s) n=11 Impella OFF % p< Bedside planar images with gamma camera Impella ON Occluded RCA/LCX Territory Pre- Support On Support 1. Remmelink, et. al. CCI, Aqel et. al. J Nuclear Cardiology, 2009 CTO of LCX and RCA untreated 2
24 27 Tandem Heart Requires septal puncture Dual vascular access Initial trials favorable hemodyamics Largest series (n=117) SRCS Inc MAP, MVO2, Dec PCWP Inc u/o, dec lactate 20% major compl 60% survival at 30 days Burkhoff et al, Am Heart J 2006;152:e1-e8. Kar et al, J Am Coll Cardiol 2011;57:
25 Cardiohelp Portable ECMO Device
26 Impella Unloading ECMO Patient Reduction in pulmonary congestion and LV dimension Jouan et al, J Hrt Lung Transplant, June 2009
27 30
28 What do these people have in common?
29
30 Bi-ventricular support using Right Atrial placement of the HeartWare HVAD: A Case Series of Consecutive INTERMACS 1 Patients. Hao A. Tran MD, Travis L. Pollema DO, David P. Cork MD, Michael A. Gibson MD, Barry H. Greenberg MD, Denise D. Barnard MD, Jorge Silva-Enciso MD, Eric D. Adler MD, Victor G. Pretorius MBchB Evaluation Parameter Patient General Age (years) Labs Gender Female Male Male Male Male Male Male Cr (mg/dl) AST (IU/L) ALT (IU/L) T Bili (mg/dl) MvO 2 (%) Echo LVEF (%) LVEDd (cm) Cath RVSP (mmhg) RVID (cm) TAPSE (cm) RAP (mmhg) PCWP (mmhg) mpap (mmhg) CI (L/min/m 2 ) , , , , , , , , , , , , , , PVR (WU) , CVP/PCWP , RVSWI , (g/m 2 /beat) 2 INTERMACS Profile (P) P1 P1 P1 P1 P1 P1 P1 U Penn RV Risk Score U of Michigan RVFRS Utah RV Risk Score CRITT Score Kormos et al RV Risk Study
31 34
32 One Heart Goes to Two People
33 Conclusions Overall mortality rates in AMI Cardiogenic Shock with inotropic/pressor or IABP support have not improved, and may be increasing in PCI Protocols for early identification, early support, and changing the focus to myocardial recovery for better outcomes and quality of life are needed Hemodynamic support with Impella promotes myocardial recovery by stabilizing hemodynamics, unloading the left ventricle, and perfusing the coronaries and end organs Treatment of cardiogenic shock with Impella is one of the most cost effective therapies available in clinical practice
34 Team Heart Success 37
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