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Mechanical Support for Acute Cardiogenic Shock
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  1. Mechanical Support for Acute Cardiogenic Shock Mark J. Russo, MD, MS Assistant Professor of Surgery Section of Cardiac and Thoracic Surgery University of Chicago

  2. Disclosures No relevant disclosures

  3. Severe Acute Cardiogenic Shock • Associated w excessive mortality • If untreated will lead to imminent death • Etiology: Post-cardiotomy, AMI, Myocarditis, Acute on chronic cardiomyopathy, Malignant arrhythmia • Goals: Must rapidly stabilize and “rest” heart • Treatment: Mechanical support + OMM • Endpoint: Recovery • Definitive surgical therapy should not be offered in the acute setting

  4. When and How to Initiate MCS

  5. Simple Rules for Initiating MCS • Pt continues to deteriorate despite increasing drugs • Initiate before the patient absolutely needs it • If you put an unsalvageable patient on MCS, they remain unsalvageable • Its not the devices that are bad, it’s the patients who are sick

  6. Hard Parameters for Initiating MCS • Already on inotropes and IABP Increasing support level required • Hemodynamics – must maintain • CI >2.0 • BP mean >60mmHg • SBP> 85 mmg • CVP <15 • PCWP <20 • End organ function : renal, hepatic, pulmonary, cerebral • Balance • Hemodynamics not attainable • Increasing inotrope requirements especially vasoconstrictors

  7. MCS Options • Partial Circulatory Support • Full Circulatory Support • Full Cardiopulmonary Support

  8. Partial Circulatory Support • IABP • Impella/Abiomed • Subclavain-IABP

  9. Impella Abiomed • Micro rotary pump • 2.5 • Cath lab, percutaneous insertion • 5.0 (larger, more flow) • Graft or cutdown • Advantages • Easy to insert • Active de-compression of LV • Less invasive • Less support than rotary pumps

  10. Impella Abiomed

  11. Subclavian Intra-Aortic Balloon • Intra-aortic balloon pumps (IABPs) are traditionally inserted through the femoral artery, limiting the patient’s mobility. • Advantages of SC: • PVD less of an issue, • minimally invasive support, • ambulatory • Limitations: • Time (40-1 hr), peri-stable, • Connective tissue disease

  12. Subclavian Intra-Aortic Balloon • The graft is then tunneled into the pocket. • The guidewire is though the skin and then into the graft and then through the subclavian artery into the aorta. • Under fluoroscopic guidance, the balloon wire is positioned in the descending thoracic aorta. • The balloon is inserted and screened into an appropriate position. • The wound over the Gore-Tex graft is closed in layers.

  13. Operative Approach

  14. Ambulating with IABP

  15. Outcomes (n=20) • Mean duration of support : 21 days (range: 3 – 90) • 19 patients (95%) were successfully bridged to transplant or LVAD. • 2 patients (10%) required an emergent LVAD for worsening heart failure. • All patients were extubated and ambulatory within 24 hours following the procedure • No device-related complications while on support • 1 device exchanged at bedside Introduction Methods Results Conclusions

  16. Full Circulatory Support • Extracorporeal VADs • LVADs • RVADs • BIVADs • Implantable VADs – are not for acutely decompensating patients • Surgical trauma • Bridge to ?

  17. Management options – what to support? • LVAD • ECHO (function and MR) • High filling pressures with hypotension and low CO • PCWP >18 with mean BP <70mmHg and CI<1.8 • RVAD • ECHO (function and TR) • CVP > 15mmHg with mPA < 1.5 x CVP • Underfilled LV • mPA > 2x CVP relative exclusion (may need LVAD or ECMO)

  18. Centrimag • Indications: • Short-term support (<15 days) • Bridge-to-decision (recovery vs definitive therapy) • Device: • a single-use centrifugal pump, a motor, and a primary drive console. • the motor magnetically levitates the impeller, • achieving rotation with no friction or wear • rotates at 1500-5500 rpm • Flows: up to 9.9L/min

  19. LVAD cannulation • Surgical • Outflow from device • Aorta, femoral artery • Inflow to device • LA/PV • LV

  20. Centrimag • Off Pump • Sternotomy • Left Thoractomy

  21. RVAD cannulation • Surgical • Outflow from device • PA - Do not push in too far • RVOT across PV • Inflow to device • RA – careful positioning • RV • Percutaneous • Outflow from device • Via long cannula to PA • Inflow to device • Femoral vein, IJ, subclavian

  22. Advantages of Centrimag • Relatively inexpensive • Reliable • High level of support • Allows for further esculation of care • Implantable device • RVAD • ECMO

  23. Case • 65 year old male • S/P traumatic right BKA after MVA • Fully functional, employed as businessman • Crescendo chest pain for 2 weeks, neglected • Unrelenting angina for 24 hours before presenting to ER • LHC performed

  24. Coronary angiogram

  25. Patient course • Emergency IABP placed • Transferred to tertiary care center • Hemodynamic data • BP 70/50 augmented • PA 45/27 • CVP 16 • CI 1.2 • Labs: Cr 2.5; TB 4.0; AST/ALT >1,000 • Support: IABP, dopamine 20 mg/kg/min, dobutamine 20 mg/kg/min, ventilator with paO2 70 on FIO2 80%

  26. Patient course • Anuric • Peripherally cold • Obtunded • ECHO: • No AI • Severe MR • Moderate TR • LVEF <10%, without thrombus

  27. Hospital course • Centri-Mag LVAD placed off pump. • Reversed acidosis • Recovered renal and hepatic function • Pulmonary edema resolved • Total CT output <300cc • Anticoagulation started POD#1 • Extubated POD#3 • HeartMate II placed POD#5 to allow for rehabilitation

  28. Full Cardiopulmonary Support • Heart and pulmonary failure • ECMO • Standard (Thoratec Centri-mag/Maquet Quadrox) • Portable (Maquet Cardiohelp)

  29. Criteria • With optimized ventilator settings • pO2 < 65mmHg • Sa02 < 90% • PEEP > 10

  30. Standard ECMO: Centrimag + Quadrox Centrimag Quadrox

  31. In Situ Centrimag Quadrox

  32. Advantages of Centrimag/Quadrox • High level of support • Reliable • Relatively Inexpensive • Peripheral/Percutaneous/Central Access • Oxygenator can be cut-in to BIVAD/RVAD circuit at the bedside

  33. Disadvantages of ECMO • It does not decompress the heart • unless LV vent placed • Contraindicated in moderate to severe AI • Oxygenator induced inflammatory response • Need for anticoagulation • ACT 150-200

  34. CARDIOHELP – INSPIRING INNOVATIONS

  35. CRITICAL CARE MEDICINE POSSIBLE APPLICATIONS • Acute Respiratory Distress Syndrome (ARDS) • Septic Shock Syndrome • Multiple Organ System Failure • Pulmonary Embolism

  36. CARDIOHELP • All in one heart-lung support system • 10 kg (22lbs) • 14 x 10 x 17 inches • Optional Sprinter Cart for in hospital mobility

  37. Operating Room: Hybrid OR / Cath Lab: General Surgery Neurosurgery Cardiac Surgery Vascular Surgery Interventional Cardiology Procedures Critical CareUnit: Patient Transport: Cardiac Care Neonatal Intensive Care Options

  38. TRANSFER OPTIONS • Transfer pt and initiate at accepting center • Transferring center initiates ECMO • Convert to Cardiohelp • Accepting initiates ECMO on site using Cardiohelp In cardiovascular disease, we have a just say “YES” policy

  39. Case • 54yo M p/w CP to outside ED • Troponin 20 • Taken to cath lab • Found to have RCA occlusion • Intervention unsuccessful • Worsening stability c high dose pressors • Intubated/IABP placed • Transferred to UofC

  40. Case • Airlifted to UofC • Directly to the OR • Peripherally cool, MAPs 55, anuric, SaO2 85% • Lactate: 7, pH 7.21, pO2 57 • ECHO: severe RV failure, LVEF=35%

  41. Case • Peripheral cannulation via femoral cutdown • RFA – arterial inflow • RFV – venous drainage • Antegrade to RFA via 12Fr cannula

  42. Case • OR • Flow: 6.0L, FiO2=100% • MAPs 70s, SaO2=100% • HD#1 • Weaning pressors • CVVHD • pH normalized, PaO2=300s • HD#4 • Off pressors and inotropy

  43. Case • HD#6 • Weaned from ECMO after 2 day wean • Wean flows • IABP, inotropy • HD#10 • Extubated • HD#12 • Off inotropy • HD#19 • Discharged to rehab

  44. Support initiated – then what? • Maintenance: • Anticoagulation • Initial – ECMO ACT 150 – 180, VAD none • After bleeding stops – 150 – 180 sec • Minimize inotropic support • Evaluate cerebral and other end organ function • IABP for some pulsatility • End goals: • Recovery and wean • Bridge to longer term solution • Definitive surgical treatment is not appropriate in acute setting

  45. Weaning / recovery • Native ejections with decreasing support • Allow time to re-equilibrate • Continuous SG useful for LVAD (even for RVAD as it give MVO2 saturation) • ECHO • Minimize anesthesia • Bad sign if escalating inotropes or requiring IABP

  46. Outcomes • Difficult to characterize given heterogeneity of patients • Recovery depends on ability to repair myocardium • Bridge to device depends on: • Earlier initiation of mechanical therapy • Single vs bi-VAD support • Liver function marker for survival • Respiratory status • Neuro • Reports vary from 30 – 80% success rates

  47. Summary • Paradigm shift • Initiate earlier • Better less inflammatory technology • Easier to initiate • Better Outcomes

  48. Take Home Points • MCS should be initiated early • Temporary support, not implantable device • Definitive therapy should only be offered after patient demonstrates measurable recovery