Dr Stephen Pettit, Consultant Cardiologist
Cardiogenic shock Management of Cardiogenic Shock Outline Definition, INTERMACS classification Medical management of cardiogenic shock PA catheters and haemodynamic targets Mechanical circulatory support Intra-aortic balloon pumps VA ECMO Short-term ventricular assist devices
Definition Clinical criteria Hypotension (systolic BP <90 mmhg for 30 minutes or need for support to maintain systolic BP of >90 mmhg) AND Heart rate of >60 bpm AND End-organ hypo-perfusion: cool extremities, urine output <0.5 ml/kg/hr, serum lactate >2 Haemodynamic criteria Cardiac index of <1.8 L/min/m 2 AND Pulmonary-capillary wedge pressure of >20 mmhg
Spiral to death if untreated
INTERMACS classification INTERMACS Description Action 1 'Crash and burn' Need to do something now 2 'Sliding on inotropes' Need to do something in the next few days 3 'Stable on inotropes' Need to do something in the next few weeks
Initial management steps Move appropriate patients to high dependency area Invasive pressure and cardiac output monitoring Do they really have cardiogenic shock? How sick is the patient? Lactate and mixed venous SaO 2 (70=good, 60=OK, <50=bad) What is the trajectory? Optimise medical therapy Identify and treat any co-existent pathology Try to lower intra-cardiac filling pressures (mean RA and PCWP) Think about inotropic and vasoactive drugs
Inotropic and vasoactive drugs Use the smallest dose of the most appropriate medication for the shortest length of time Francis GS et al. J Am Coll Cardiol 2014;63:2069 2078.
Need Cardiac Power to survive in SHOCK CPO = (MAP x CO)/451 0.6x451 = MAP x CO 270 = MAP x CO Therefore aim for MAP 70 and CO 4 Fincke R et al. J Am Coll Cardiol 2004;44:340-8
Phone for help if transplant/mcs candidate
There is a mountain to climb Get through early post-operative care Perform heart transplant or durable LVAD implant Allow end-organ recovery Achieve reasonable MAP and CO
Goals of Mechanical Support Unload injured ventricles Wean toxic levels of vasopressors Maintain end-organ perfusion/function Allow cytokines to be metabolised Allow replenishment of ATP stores Allow myocardium to declare potential for recovery
What MCS options are available? Peripheral Central
Intra-Aortic Balloon Pump
IABP increase MAP and decrease afterload
IABP do not improve outcome in post-mi shock Thiele H et al. New Engl J Med 2012;367:1287-1296
Veno-arterial (VA) ECMO
Indications for VA ECMO Acute heart failure of any cause Acute myocardial infarction complicated by cardiogenic shock Acute myocarditis Decompensated chronic heart failure Failure to wean from cardiopulmonary bypass Routine cardiac surgery Heart transplantation Cardiac arrest (ECMO-assisted CPR)
SAVE score predicts survival but not benefit Schmidt M et al. Eur Heart J 2015;36:2246-56
When not to initiate VA ECMO Futile treatment without exit strategy in case of; Unrecoverable heart function in non-transplant/lvad candidate Active malignancy Severe neurological injury or psychiatric disease Severe chronic organ dysfunction (COPD, cirrhosis of liver, renal failure) Problem that makes VA ECMO ineffective/dangerous Moderate to severe aortic regurgitation Peripheral vascular disease Uncontrolled bleeding Unwitnessed cardiac arrest or prolonged CPR
Highly complex Management of Cardiogenic Shock Management of VA ECMO patient Cardiovascular targets Blood flow 2.5-4 L/min Mean arterial pressure 60-80 mmhg Oxygen saturation >90% (arterial) and >70% (mixed venous) Anti-coagulation and transfusion IV heparin infusion, aiming for APR 1.5-2 Hb >80 g/l (or Hb >100 g/l if SvO 2 <70%) Platelets >100 if bleeding Nutritional support, watch lungs, limbs and neurology closely
Risk of limb ischaemia with VA ECMO Need re-perfusion line to avoid limb ischaemia
Risk of LV distension/thrombosis with VA ECMO Rising LVEDP Leading to pulmonary oedema Then LV distension, stasis and thrombosis
Risk of Harlequin syndrome with VA ECMO Watch SaO 2 in right radial artery and ST segment on ECG. Optimise ventilation. May need VAV.
Complications during VA ECMO are common Adapted from Cheng R et al. Ann Thorac Surg 2014;97:610-6.
Moving on from VA ECMO VA-ECMO Medical therapy CentriMag BiVAD Durable LVAD Recovery Palliation Transplant
Survival from VA ECMO to discharge is 30-40% Adapted from www.elso.org/registry/statistics/internationalsummary
Percutaneous LVAD Impella family 2.5: Percutaneous, left-sided CP: Percutaneous, left sided RP: Percutaneous, right sided 5.0: Femoral cut-down Pro: Quick to insert (Impella 2.5, CP, RP), can assess RV function Cons: Expensive, dislodgment, <3.5L/min, haemolysis, aortic incompetence
Tandem Heart Pro: Percutaneous or open, works with any cannula, LVAD/RVAD, +/- ECMO Cons: Expensive, trans-septal puncture needed for percutaneous use
CentriMag LVAD and/or RVAD Pro: Excellent flow rates, reliable, long duration of support, cost-effective Cons: Sternotomy to implant, infection risk
CentriMag LVAD and/or RVAD
Summary Cardiogenic shock is usually fatal if untreated PA catheter may be useful for diagnosis and guiding treatment Use inotropes or vasoconstrictors with caution, consider IABP Watch end-organ function Consider MCS before multi-organ dysfunction occurs Peripheral options favored in sickest patients (INTERMACS 1) Central options may provide longer-term support Implantable LVAD for most stable patients Start with the end in mind
Any questions?