Cardiogenic Shock: Which Mechanical Support Should We

Use as First Line Option?

Mariell Jessup MD FAHA, FACC, FESCProfessor of Medicine

University of PennsylvaniaPhiladelphia, Pennsylvania, USA

Disclosure: Mariell Jessup MD

• Speakers Bureau:• Advisory Board:• Honorarium:

University of Pennsylvania

NONE

Temporary support:Background

• Cardiogenic shock– Compromise of cardiac output leading to end-

organ hypo-perfusion– Complex cascade of end-organ dysfunction

combined with activation of inflammatory pathways

– Complicates about 7% of ST segment elevation MI1 and about 2.5% of non-ST segment elevation MI2

1Holmes DR Jr, Berger PB, et. al. Circulation 1999; 100:2067–2073.2Hasdai D, Harrington RA, et. al JACC 2000;36:685–692.

Who would benefit from temporary support?üAcute cardiogenic shock

Acute myocardial infarctionAcute myocarditisComplications post MI

Papillary muscle ruptureVentricular septal defect

üPost cardiotomy failureüAcute on chronic (end-stage) heart failureüElectrical “storm”, or post-VT ablation üDrug overdose with myocardial depressionüHypothermia

Windecker S. Curr Opin Crit Care 13:521–527. 2007

the OPTIONS

Sick patient

Temporary supportChronic support

Unclear situation

1. Support circulation2. Oxygenate patient

Choice dictated by clinical status:temporary supportECMO

Durable VADs pulsatile non-pulsatile

Illustrative cartoons are helpful….

but these patients are desperately ill.

Important Principles

• Definition of success– Survival without device– Transplant– Survival on dialysis– Transplant on dialysis– Durable device on dialysis

• Availability of devices• The appropriate setting of care

– Should the patient be transferred?

~ ½ of the patients who need an MCSD for shock survive, and ~ ½ of these survivors require an

implantable VAD. Ongoing CPR is predictive of in- hospital

mortality.

“In our series, the sickest patients died during the first 24–48 h of ECLS,obviating the use of LVAD. Furthermore, one-third of our ECLS patients recovered without LVAD or heart transplantation because of reversible cardiac dysfunction,

thus avoiding the risk of a VAD implantation.”

RV function ?? renal function ??

Especially in the patient with renal failure

UNOS registry2000-2010

13,250 patients with first transplant

The overall survival in our cohort was 31%. While patients without the need for RRT showed a 98-day survival of 53%, patients

with RRT had an overall survival of 17%.

Decisions to make during the “bridge to decision”

• Age of the patient• Frailty of the patient• Social support of the patient• End of life wishes• Transplant candidate?

– Infection, pulmonary infarct, cancer• Co-morbidities

– Weight, vascular disease, neurologic status

The pump choices for the acutely ill patient.

• Intra-aortic balloon pump• Extracorporeal membrane oxygenation

(peripheral cardio-pulmonary bypass)• Tandem Heart• Impella

• Traditional ventricular assist devices• Total Artificial Heart

Percutaneous

SurgicalCentriMag

Advantages of Percutaneous Device

• Placed quickly• Avoid need for “open surgery”• Placed at many centers: even those without

VAD or transplant program• More easily removed in setting of recovery• Placed by interventional cardiologists and

surgeons• Allow for recovery or transport to another

center

Disadvantages of Percutaneous Devices

üBleedingüLimited to left ventricular support (except ECMO)

Not for biventricular support Not for RV support (CentriMag can be used)Ventricular arrhythmias

üIschemic limbüUnable to mobilize or rehabüSepsis

Intra-aortic Balloon Pump

IABP - Advantages• Easily placed in the catheterization

laboratory or operating room• Improves coronary perfusion• Decreases afterload• Decreases myocardial oxygen demand• Can transport patient to another center• Established technology that is widely

available

IABP Disadvantages

• Does not directly support cardiac output• Limited support in the setting of tachycardia

and arrhythmia• May be less effective in older patients with

significant atherosclerosis in aorta

Impella

Impella Advantages

• Small rotary pump• Can be placed percutaneously from femoral

artery across aortic valve without need of trans-septal puncture or venous access

• Can be easily removed

Impella Disadvantages

• Hemolysis – although not felt to be clinically relevant

• Provides partial cardiac output support – up to 2.5 liters/minute in percutaneous model; up to 4-5 liters/minute with model 5.0

• Difficult to place in setting of severe peripheral vascular disease

Impella: Datathe ISAR-SHOCK trial

Seyfarth M, Sibbing D., et. al. JACC 2008;52:1584–8

Improved cardiac power index No difference in survival

Tandem Heart

Tandem Heart Advantages

• Can be placed easily in the catheterization laboratory

• Can supply up to 5 l/min flow• Can be easily removed

Tandem Heart Disadvantages

• Requires trans-septal placement• Difficult to place in setting of severe

peripheral vascular disease

Tandem Heart Data

• Compared to IABP in acute MI with shock (n=41) (Single Center)– Improved cardiac power index, decreased

lactate, improved renal function as compared to IABP

– No difference in 30 day survival and more complications in Tandem Heart group

Thiele H, Sick P, et al. Eur Heart J 2005; 26:1276–1283.

Tandem Heart Data

• Multi-center trial comparing Tandem Heart and IABP in acute MI with shock (N=42)– Tandem Heart improved cardiac output,

decreased PCWP and increased mean arterial pressure as compared to IABP

– No difference in 30 day survival– Similar complication rates

Burkhoff D, Cohen H. Amer Heart J, 152:3, September 2006.

Cheng, JM et al. European Heart J 2009; 30: 2102

30-day mortality

Cheng, JM et al. European Heart J 2009; 30: 2102

ECMO

http://www.emedicine. medscape.com/article/904996-overview

ECMO - AdvantagesüCardio-pulmonary bypassüCan be placed peripherally (without

thoracotomy)üThe only percutaneous option for biventricular

support üThe only option in the setting of lung injury

ECMO - Disadvantages

• Requires trained team and equipment availability on-site and early in resuscitation

• Higher risk of infection, bleeding and vascular injury

Acute Refractory Cardiogenic ShockAcute Refractory Cardiogenic Shock

Temporary VAD/ECMO SupportTemporary VAD/ECMO Support

Recovery/AssessmentRecovery/Assessment

Long-term MCSLong-term MCS

Bridge toBridge to TransplantTransplant DestinationDestination TherapyTherapy BridgeBridge to Recoveryto Recovery

MSOFMSOFNeurologic DeficitNeurologic Deficit

MCS ExplantMCS Explant

Medical TherapyMedical TherapyIABPIABP

Revascularization,Revascularization, surgery surgery

Palliative CarePalliative Care

RehabilitationRehabilitation

Rapid Deterioration (hrs)

MCS in Cardiogenic Shock: Management Algorithm

Gregoric I, Bermudez C. Braunwald Comp., Mechanical Support 2011

Days -Weeks

Limitations of all of this….

• Studies done to date have been small and at a limited number of centers

• Inclusion and exclusion criteria are challenging in the setting of sudden shock

• Populations studied have been somewhat heterogeneous including acutely and chronically ill patients

• The data for “prophylactic use” to support procedures is very encouraging

Issues in the implantation of durable VADs

• Proper selection of patients– Recognizing the patient who is “too sick”, with end-

organ damage– Recognizing the patient who is too debilitated or

malnourished– Recognizing the patient who needs bi-ventricular

support• Timing of surgery

– Especially important in the elderly “destination” patient

Sick patient

Temporary supportChronic support

Unclear situation

1. Support circulation2. Oxygenate patient

Choice dictated by clinical status:temporary supportECMO

Durable VADs pulsatile non-pulsatile

Which Mechanical Support Should We Use as First Line Option?

• The one you have experience with…..• Start simple and think about the appropriate

setting for the patient.• Before you transfer the patient, get all the

details of the medical and social history!• Ask for help, please

Thank You