Cardiogenic Shock. Dr. JPS Henriques. Academic Medical Center University of Amsterdam The Netherlands

Transcription

1 Cardiogenic Shock Dr. JPS Henriques Academic Medical Center University of Amsterdam The Netherlands

2 Conflict of interest disclosure Research grant Abbott Vascular Research grant Abiomed Inc. Global Impella Advisory board member

3 3 Cardiogenic shock - Agenda 1. Acute Myocardial infarction setting 2. Brief overview various target therapies 3. The role for mechanical support?

4 Mortality in CS AMC SHOCK Trial AMC Euro Heart Survey IABP- SHOCK 2 pre-thrombolysis Thrombolysis Primary PCI IABP Goldberg et al. NEJM 1999; Hochman et al. NEJM 1999; Sjauw, Henriques et al. NHJ 2012 Zeymer et al. Eurointervention 2011; Thiele et al. ESC 2012

5 STEMI + CS - DEATH <10% of all STEMI but accounts for 90% of mortality Revascularization Metabolic pathways Mechanical assist devices Hochman, J. S. Circulation 2003;107:

6 Metabolic pathways Inotropic and vasopressor agents The good Improve haemodynamic parameters rapidly in CS. The haemodynamic benefits are perceived to outweigh the risks because hypotension itself compromises myocardial perfusion. Pharmacological circulatory support is recommended in CS

7 Metabolic pathways Inotropic and vasopressor agents The bad Increase myocardial oxygen consumption Can cause myocardial ischaemia Can cause ventricular arrhythmias, Can cause contraction band necrosis Can cause infarct expansion Pharmacological circulatory support is recommended in CS. Although these drugs have not shown to improve patient outcomes in randomised controlled studies.

8 Revascularization SHOCK 30 days 46,7% vs 56.0%, P=0,11 80% IABP 80% IABP Hochmann, NEJM 1999

9 Revascularization SHOCK long term Hochmann, NEJM 1999, JAMA 6 months mortality 50.3% vs 63.1%, p=0.03, NNT 8

10 Mechanical assist devices Mechanical Circulatory Support STEMI STEMI + CS Myocardial recovery Myocardial recovery Organ recovery Mechanisms - acceleration recovery of contractility in stunned myocardium by increasing postischemic myocardial (microvascular) blood flow. - unloading effect: peak left ventricular wall stress myocardial workload reduced myocardial oxygen consumption. Sjauw KD, Engström AE, Henriques JPS; Percutaneous Mechanical Cardiac Assist In Myocardial Infarction. Where Are we Now, Where Are We Going? Acute Card Care 2007;9(4):222-30

11 Mechanical assist devices Currently available devices IABP TandemHeart Impella 2.5 Impella 3.5 (CVAD) Impella 5.0 (surgical insertion) Minituarized ECMO

12 IABP - The guidelines ACC/AHA Class 1B although no data support a reduction in mortality rates ESC Class 1C

13 IABP in STEMI Randomized controlled trials Sjauw KD, et al. Eur Heart Journal, 2009

14 IABP in STEMI Randomized controlled trials Sjauw KD, et al. Eur Heart Journal, 2009

15 The CRISP AMI Trial N=337 Patel MRet al, JAMA, 2011

16 Cardiac Power Output (CPO in Watts) No Hemodynamic Benefit of IABP in recent RCT 1.5 IABP (n=19) No IABP(n=21) N.S Inotrope dosage was similar between the 2 groups 0 p<0.011 Prior Time in hours Prondzinsky et al. SHOCK 2012;37: (Clinical Trials.gov ID NCT )

17 N=600 IABP vs optimal medical therapy in STEMI with CS on top of PCI Hotline session earlier today PI - Holger Thiele

18 IABP-SHOCK 2 - Lactate Thiele et al. Presented ESC Congress Munchen 2012

19 IABP-SHOCK 2 Primary enpoint 30 days Thiele et al. Presented ESC Congress Munchen 2012

20 New devices provide more support Thiele Eur Heart J 2005 Burkhoff Am Heart J 2006

21 More support Outcome? TandemHeart vs. IABP in STEMI+CS Meta-analysis KD Sjauw, AE Engstrom et al Acute Cardiac Care, 2007 Venous sheath 21F Transseptal puncture - inflow left atrium. 15F or 17F arterial cannulae. ACT > 200 seconds during support Not easy Time consuming Learning curve Limb ischemia Bleeding

22 22 Role of Ventricular Unloading? ECMO vs. Impella in Heart Failure Model Heart vs. Organs Kawashima D, et al. ASAIO Journal 2011

23 Regional Cardiogenic Shock Centers 5 years 93 pts 1. Go out to the patient 2. Start local facility 3. Transfer to expert shock center Beurtheret S et al. Eur Heart J, 2012

24 Better unloading + more support

25 Myocardial recovery IMPELLA 2,5 Unloading in STEMI Non randomized pilot study Engstrom AE, et al. EuroIntervention, feb. Academic 2011 Medical Center, Amsterdam, The Netherlands

26 Impella 2,5 Euroshock registry Lauten A, Engstrom AE, et al. Circulation Heart Failure, In Press

27 Are all devices equal? Upgrade? What parameters used? 40 Impella 2.5 Upgraded Impella Survivors (n) Baseline 6 hours 48 hours 30 days Engstrom AE, et al. Critical Care Medicine,20 3

28 Implemented AMC strategy Mech. ventilation + Mech. ventilation - cvad Impella device 14 Fr providing >3,7 L/min recently CE approved

29 Ongoing STEMI trials with IABP and Impella CRISP AMI ISAR SHOCK 2 MINI AMI IMPRESS IN STEMI Anterior AMI STEMI + CS Large STEMI STEMI + pre-cs IMPRESS in Severe Shock 2,5 2,5 Completed Completed Initiating Stopped Slow inclusion cvad 5 patients in 5 weeks One center 21 patients in 4 years 5 centers

30 Conlusion? In absence of evidence At least Revascularize. Support yes or no? Drugs and/or Devices? Before or after PCI

31 Future perspectives Appropriately change the guidelines Easy bedside measures of shock grading (for valid and reproducible comparison) We need to execute these difficult studies (CS out of expert opinion into evidence based medicine)

32 See you next year in Amsterdam! Thank you for your attention