cardiogenic shock from ecmo to percutaneous vadscardiogenic shock from ecmo to percutaneous vads...
TRANSCRIPT
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Cardiogenic shock From ECMO to percutaneous VADs
Shinya UnaiStaff Surgeon
Thoracic and Cardiovascular Surgery
Cleveland Clinic
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Disclosures
• None
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Outline
• Mechanical support for cardiogenic shock
• Unloading the ventricle
• High risk cardiac surgery
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43yo maleAMI PCI to LAD
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How do we support?
IABP/inotropes, C.I 1.4, VT, FiO2 100%
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Aortic Counterpulsation
IABP
LV
Impella2.5/CP/5.0
TandemHeart
Centrimag
RV
Impella RP
Protek Duo
Centrimag
BiV
Impella RP + 5.0
Centrimag
Heart/Lung
ECMO
Centrimag
Long Term
Support
HeartMateII
HeartMateIII
HeartWare
Total Artificial Heart
Long-term options with IABP
Long-term options with IABP
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Aortic Counterpulsation
IABP
LV
Impella2.5/CP/5.0
TandemHeart
Centrimag
RV
Impella RP
Protek Duo
Centrimag
BiV
Impella RP + 5.0
Centrimag
Heart/Lung
ECMO
Centrimag
Long Term
Support
HeartMateII
HeartMateIII
HeartWare
Total Artificial Heart
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Aortic Counterpulsation
IABP
LV
Impella2.5/CP/5.0
TandemHeart
Centrimag
RV
Impella RP
Protek Duo
Centrimag
BiV
Impella RP + 5.0
Centrimag
Heart/Lung
ECMO
Centrimag
Long Term
Support
HeartMateII
HeartMateIII
HeartWare
Total Artificial Heart
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Aortic Counterpulsation
IABP
LV
Impella2.5/CP/5.0
TandemHeart
Centrimag
RV
Impella RP
Protek Duo
Centrimag
BiV
Impella RP + 5.0
Centrimag
Heart/Lung
ECMO
Centrimag
Long Term
Support
HeartMateII
HeartMateIII
HeartWare
Total Artificial Heart
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CentriMag
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1953 Mayo-Gibbon pump
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Reperfuson cannula
Venous
Arterial
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VA ECMO for Cardiogenic Shock
Pro’s• Quick
• Bedside application
• Minimally invasive
• Biventricular support
• Pulmonary support
• Time to evaluate
Con’s• Non-pulsatile
• Limb ischemia
• LV distension
• Pulmonary edema
• Coronary perfusion
• LV/Aortic thrombus
• Cerebral hypoxia
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VA ECMOPulmonary edema
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Increased afterload +
LV standstill
LV distension
IABPInotropes
Anticoagulation
LV vent
Septostomy
Pulmonary
edema
LV thrombus
Apical
cannulation
Impella
(EC-Pella)
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Impella 5.0 placement
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Cardiogenic shock with
cardiopulmonary collapse
Percutaneous
VA ECMO
+/- IABP
Wean VA ECMO
8Fr Reperfusion
Sheath
Continued VA
ECMO+Impella support
5.0 Axillary Impella
(EC-Pella)
SHOCK TeamVA (VAV) VV ECMO
Wean VA ECMO,
Add Impella RP
Permanent LVAD
Heart transplant
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Eventually LVAD implant
• Discharged from acute rehab
• Feeling “pretty good”
• Walking, denies SOB
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10% improvement with revascularization
Hochman JS et al. NEJM 1999; 341:625-634.
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15% long-term improvement
Reynolds H R , Hochman J S Circulation
2008;117:686-697
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Can we do better?
• Hemodynamic support
• Unloading
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Hemodynanmic effect of Impella
Coronary
Perfusion
Microvascular
Resistance
LVEDP and LVEDV
O2 Demand
Unloading to Myocardial Recovery
O2 Supply
Mechanical
WorkWall
Tension
Cardiac Power Output
Flow
End Organ Perfusion
MAP
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5X Reduction in Infarct Size
Infarct
with offloading
Infarct
Swine LAD Occlusion Model
Without off-loading With off-loading Kapur, JACC HF, 2015
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Left Ventricular Unloading: Timing
Esposito, JACC, 2018
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Impella pre-PCI associated with improved survival in AMI/CGS
1. Abiomed Impella Quality (IQ) Database, US AMI/CGS Apr 2009– Jan 2017. Survival to device explant. Danvers, MA: Abiomed.
2. O’Neill et al., J Int Cardiol 2014;27:1-11. Survival to hospital discharge
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40yo male, 8.6cm LVEDD
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High risk Cardiac Surgery
• Hemodynamics (CI<2.0, PAPi<1.0)
• Decompensated HF
• Contractile reserve• Frailty
• End-organ dysfunction
• Viability, Target
• Porcelain aorta, severe MAC, multi redo…
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Post-Cardiotomy Cardiogenic Shock
• 0.2-9%, 0-75% mortality
• risk in low EF
• high-dose inotrope
• long CPB0
20
40
60
80
100
Amount of Inotropic Support
Peri
op
era
tive M
ort
ality
(%
)
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Effect of LVEF
0
5
10
15
20
25
30
mortality CVA RF Vent
EF < 25 25 - 35 35 - 45Shahian, ATS, 2009.
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CCF High Risk Evaluation
High Risk CABG/Valve(targets, EF, viability; STS score)
High RiskTemporary MCS support
Recovery-only
? CMS DT
criteria
? UNOS BTT
criteria
Low - Moderate RiskUnlikely to need support
Ischemic: viability,
wall thickness,
ischemia
Contractile reserve
1. ECHO: LVEDD(<7.5), RV
2. RHC: CI, PAPi
3. PET/cMRI/Dobutamine stress
4. HF Cardiology
5. Social work evaluation
6. AHFTC adjudication
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Preoperative Optimization
• Swan-guided inotropes, vasodilator therapy
• Possible pre-operative temporary MCS
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Operative Steps
10mm graft
Vessel loops left in
for removal
Right axillary 10mm graft
Standard cannulation for CPB
Advance Impella after cross clamp off
Gain access across aortic valve using TEE and floroscopy
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Post op course
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Impella-Assisted Revascularization
• High risk CABG: 3-7day recovery (>48hr)
• High-risk PCI- Normal EF: PCI with femoral Impella CP
- Low EF: Impella 5.0 1 day before PCI, 3-7day recovery (>48hr)
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Impella-Backup for high risk cardiac surgery
• LF/LG AS with no/low contractile reserve
• Severe AI with low EF
• Severe FMR with low EF
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Recent Paradigm Shifts
• Postoperative IABP Axillary 5.0 Impella- Completely wean inotropes/pressors
- Early extubation/ambulation
- Lower ICU/total LOS, overall better outcomes
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Conclusions
• Multidisciplinary, shock team approach
• Early mechanical support with LV unloading
• Impella use for PCI and high risk surgery
• Minimal use of inotropes
improved outcomes!
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