non coronary intervention circulatory support l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Non-Coronary Intervention Circulatory Support PowerPoint Presentation
Download Presentation
Non-Coronary Intervention Circulatory Support

Loading in 2 Seconds...

play fullscreen
1 / 41

Non-Coronary Intervention Circulatory Support - PowerPoint PPT Presentation


  • 100 Views
  • Uploaded on

Non-Coronary Intervention Circulatory Support. Advanced Angioplasty 2003. Andreas Baumbach Bristol Royal Infirmary. Circulatory Support. PCI / Acute MI Cardiogenic shock. Cardiac Surgery High risk CABG Weaning Bridge to transplant Chronic Heart Failure ?. Circulatory Support.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Non-Coronary Intervention Circulatory Support' - kailey


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
non coronary intervention circulatory support
Non-Coronary InterventionCirculatory Support

Advanced Angioplasty 2003

Andreas Baumbach

Bristol Royal Infirmary

circulatory support
Circulatory Support

PCI / Acute MI

Cardiogenic shock

  • Cardiac Surgery
    • High risk CABG
    • Weaning
    • Bridge to transplant
    • Chronic Heart Failure ?
circulatory support3
Circulatory Support

Balloon Counterpulsation

Results & Evidence

Guidelines

Assist Devices: Developments

intra aortic balloon pump
Intra-Aortic Balloon Pump
  • Inflatable 32-40 cc balloon
  • Triggered to inflate with helium immediately after aortic valve closure
  • Triggered to deflate with opening of the aortic valve
intra aortic balloon pump6
Intra-Aortic Balloon Pump

Decreases Afterload

Increases Diastolic Aortic Pressure

Increases Coronary Flow Velocity

Reduces Myocardial Oxygen Demand

circulatory support7
Circulatory Support

Balloon Counterpulsation

Results & Evidence

Guidelines

Assist Devices: Developments

intra aortic balloon pump current practice
Intra-Aortic Balloon PumpCurrent Practice

Results from the Benchmark Registry

Ferguson et al. J Am Coll Cardiol 2001; 38:1456

benchmark registry
Benchmark Registry
  • June 96-August 2000
  • 203 Hospitals (90%US)
  • 16909 patient case records
  • Verified by external audit

Ferguson et al. J Am Coll Cardiol 2001; 38:1456

benchmark registry indication
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

benchmark registry complications
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

iabp evidence
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

iabp in direct angioplasty
IABP in direct 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 1997

iabp in direct angioplasty14
IABP in direct angioplasty

High risk

Age>70yrs

3 vessel disease

LVEF<45%

SVG occlusion

Persistent malignant arrhythmia

Subotpimal result*

*Stents 1.3%

Stone et al. J Am Coll Cardiol 1997

iabp in direct angioplasty15
IABP in direct 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 1997

iabp in direct angioplasty16
IABP in direct angioplasty

Stone et al. J Am Coll Cardiol 1997

iabp in direct angioplasty17
IABP in direct 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 ‘

Stone et al. J Am Coll Cardiol 1997

iabp evidence18
IABP Evidence

A randomized comparison of intraaortic balloon pumping after primary coronary angioplasty in high risk patients with acute MI treated

Van ‘t Hoft 1999, Eur Heart J

iabp evidence19
IABP Evidence

N 238 over 3.5 years

118 IABP 120 no IABP

Primary endpoint: Death, Re-MI, stroke, EF<30% at 6 months FU

-> 26% vs 26%

No difference in EF

8% major complications in IABP group

Van ‘t Hoft 1999, Eur Heart J

iabp evidence shock
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;

iabp evidence shock21
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; 36:1123

shock registry
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; 36:1123

shock registry mortality
SHOCK Registry: Mortality

p=.005

p<.0001

Sanborn et al. J Am Coll Cardiol 2000; 36:1123

shock result
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

circulatory support25
Circulatory Support

Balloon Counterpulsation

Results & Evidence

Guidelines

Assist Devices: Developments

guidelines
Guidelines

“Emergency high risk PCI such as direct PCI for acute MI can usually be performed without IABP or CPS.

However, it should be noted that in patients with borderline hemodynamics, ongoing ischemia, or cardiogenic shock, insertion of an intra-aortic balloon just prior to coronary instrumentation has been associated with improved outcomes.

Furthermore it is reasonable to obtain vascular access in the contralateral femoral artery prior to the procedure in patients in whom the risk of hemodynamic compromise is high…”

AHA/ACC Guidelines for PCI, Circulation 2001

guidelines27
Guidelines
  • Recommendations for the use of IABP in the treatment of AMI
  • Class I
  • Cardiogenic shock not quickly reversed with pharmacological therapy as a stabilising measure for angiography and prompt revascularisation
  • Acute MR or VSD – as a stabilising therapy for angio and repair/ revascularisation
  • Recurrent intractable ventricular arrhythmias with hemodynamic instability
  • Refractory post –MI angina as a bridge to revascularisation

AHA/ACC Guidelines for AMI, JACC 1996, Web update 1999

guidelines28
Guidelines

Recommendations for the use of IABP in the treatment of AMI

Class IIa

Signs of hemodynamic instability, poor LV , or persistent ischemia in patients with large areas of myocardium at risk

Class IIb

Following successful angioplasty to prevent reocclusion

Large areas at risk w/o active ischemia

AHA/ACC Guidelines for AMI, JACC 1996

summary iabp
Summary IABP

Intra-Aortic Balloon Pump is an excellent tool for the management of hemodynamically unstable patients especially in the setting of acute MI

circulatory support30
Circulatory Support

Balloon Counterpulsation

Results & Evidence

Guidelines

Assist Devices: Developments

assist devices indications
Assist Devices: Indications
  • Cardiogenic shock in AMI
  • Postsurgical myocardial dysfunction
  • Acute cardiac failure from myocarditis
  • Decompensated chronic heart failure
assist devices goals
Assist Devices: Goals
  • Bridge to transplantation
  • Bridge to recovery
  • Alternative to heart transplantation

Delgado et al Circulation 2002;106:2046

devices
Devices
  • Extracorporeal Assist (e.g.Thoratec/Abiomed)
  • Implantable LV assist devices (Heartmate)
  • Axial Flow pumps
  • Totally implantable LVAD (Lion Heart)
  • Total Artificial Heart (ABIOCOR)

Delgado et al Circulation 2002;106:2046

heartmate36
Heartmate

N:129

Quality of life

assist devices
Assist Devices

Progress in technology promises new surgical treatment options for end stage heart failure

Our surgical colleagues should be pleased to finally have hearts that we won’t fix with percutaneous intervention