Cardiogenic Shock in Acute MI: Mechanical Circulatory Support€¦ · Critical cardiogenic shock...

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Cardiogenic Shock in Acute MI:Role for Mechanical Circulatory Support

Craig S Smith, M.D.4/5/19

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No Disclosures

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Coronary Syndromes: Improvement in Treatment

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Prevalence of Cardiogenic Shock in Primary PCI

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Timing is Everything...• After acute MI with Primary PCI

Vfib: 94.7% before or during PCI6.3% AV Block (86% before/during PCI: 90+% resolve)4.5% “impeding shock” coming into PCI4.2% Shock- most prehospital1% develop post PCI Can J Cardiol 2006 Oct; 22(12):1047-52.

•Shock trial: median 6.2 hours after symptom onset (74% within 1 day)LM: 1.7 hrsRCA: 3.5 hrsLCx: 3.9 hrsLAD: 11hrs Late shock (>24hours): recurrent ischemia, Q waves, LAD

JACC 2000 Sep; 36 (3 Suppl A): 1084-90.

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EVOLUTION OF THE CARDIAC CARE UNIT“..times they are a changin’ ” B Dylan

1980s

Resuscitation

1990s

Intervention

TodayComprehensive

CriticalCare

Rapid Defibrillation

Post MI Care

Gen ICU RN

STEMIs

Antiarrhytmics

All ACS

Specialized RN

CHF

IABP

Rapid Defibrillation

TTM

MCS

Advanced CHF

Pul HTN

Multidisciplinary

Performance Tracked

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Cardiogenic Shock

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• Not “just” decreased CI (def ≤ 1.8, or 2.2 with pressors, SBP ≤ 90mmHg )

• Multiorgan dysfunction syndrome due to peripheral hypoperfusion with microcirculatory dysfunction

• Complicated by SIRS (~25%)

• Once multiple systems involved, difficult to improve prognosis by merely fixing CO.

• Most due to decompensated CHF

99

1010

Exam !?

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ECG in Cardiogenic Shock

The ST pattern in Cardiogenic shock:

70-85% ST elevations MI/ New LBBB• Mortality: 53-63%

15-30 % Non-ST elevation MI• Older• Mortality: 77%

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¨ BP¡ Pulse pressure : large (elderly/AI), narrow (pre-shock)

¡ Proportional pulse pressure = SBP-DBP/ SBP¡ No BETA BLOCKERS¡ Does pulse disappear with respiration? (tamponade)¡ Pulse equal in both arms? (dissection)¡ Fistula in the arm? (Effusion)

¡ Murmur¡ New ?¡ Upper right sternal border : AS (elderly) HOCM (young)¡ Listen for the MR murmur in the back if Q waves!

¡ Neck Veins¡ TR with elevated INR think Pul HTN and RV failure¡ PRELOAD ASSESSMENT IS KEY!

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Mortality by Clinical Presentation

Mortality RespiratoryDistress Hypotension

Hypo perfusion

21%

22%

70%

60%

5.6%

28%

65%

1.4%

SHOCK Registry JACC Sept. 2000, Supp. A

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Intermacs 1

Critical cardiogenic shock describes a patient who is “crashing and burning”, in which a patient has life threatening hypotension and rapidly escalating inotropic pressor support, with critical organ hypoperfusion often confirmed by worsening acidosis and lactate levels.

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CS Level 1SBP <90 30 min pre-ionotropes

Pulmonary congestionor

Impaired end-organ perfusion:AMS

Cold/ClammyOliguria

Lactate >2

CS Level 2 (Profound)CS Level 1

CI <2.2 L/min/m or

Lactate > 3Despite

2 Ionotropes/Pressors

CS Level 3 (Deep)CS Level 2

Two of the following:Lactate > 8mmol/l

AnuriaRHF

Escalating PressorsRespiratory Failure

Courtesy of Eddie Rame MDUPENN

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Three HighDose

2% 3% 7.5%21%

42%

80%

Pre-Shock Profound ShockShock

No HemodynamicSupport

Needs Partial Hemodynamic Support

Needs Full Hemodynamic Support

Mortality Risk with Inotrope Dosing

Samuels LE et al , J Card Surg. 1999 Jul-Aug;14(4):288-93

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IABP SHOCK-2 Trial: Predictors of Mortality

Thiele et al, Lancet 2013

Univariate Multivariate

The two strongest predictors (age and prior stroke) cannot be modified by any acute intervention

The next three predictors (lactate, oliguria, and pH) suggest that the amount of LV support is important

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(Was) Controversial

Gusto 1/Shock benefit

Objective Data

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P=NS, .02@ 6mo.

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The Challenge of Age…

?

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Clinical Intuition in the Information Age:Shock in the Elderly

41%

75%

57%53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

<75 years (n=246) >75 years (n=56)

30-d

ay M

orta

lity

(%)

ERVIMS

p=0.01 p=0.01

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Elderly - SHOCK & other registry dataClinicians Needed!

48% 47% 46%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

SHOCK Registry Mayo Clinic Northern NewEngland

30-d

ay M

orta

lity

(%)

ERVIMS

n=44 n=233 n=61 n=74

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PA Cath: Resistance is not futile! Importance of SVR

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42 yo/ trop 7038.5 at hour 36 then

SVR 400Mechanical Support

LOS 12 days

64 yo/ trop 70No fever

SVR mildly upJust meds

Walked out in 3 days

55 yo diabetic/ trop 70No feverSVR high

IABPMonomorphic VT

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With RBCs and O2, Comes WBCs….

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Inflammation / NOS : Local & Systemic EffectsFever, leukocytosis, Big temp (38.5+) typically hour 24-30 Nitric Oxide (neuronal, endothelial, inducible)

•Low levels (eNOS) is cardioprotective, increases contractility

•High levels (iNOS) in inflammatory conditions particularly MI and reperfusion

– ↓ Contractility– Suppression of mitochondrial respiration in nonischemic myocardium– Alters substrate metabolism (glucose)– Reduced efficacy of catechols– Vasodilation– Interaction at high levels with free radicals causes cell death/toxicity

vs.

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Hockman. Circ 2003; 107:2998-3002

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CS Survivors…

Average EF only ~ 30%

Huge variability in SVR , may not be elevated despite vasopressors

SIRS (~20% of CS, 2 days post)

Most survivors of CS have NYHA Class I Inconsistent with >40% myonecrosis

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Hemodynamic Phenotype

Tailored Support and Decongestion Strategies

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48 yo male with 2 hours CP:

3131

3232

3333

Stormy Course

• Day 1: CVP 16, SVR 1800, CI 2.2 (MCS), MAPs OK

• Day 2: Fever to 39 C, CVP 12, SVR 600, CI 2.4 (MCS), Levophed

• Day 4: CVP 20, suction alarms on MCS, SVR 1600, CI 1.9 (MCS), Milrinone

• Day 9: antibiotics CVP 6, SVR 600, CI 3, Neo and fluids

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Shock mortality predictor ≠ CI, CO, SVR, PCWP but rather reserve pumping capacity.

Heart pump dependent on preload and resistance circuit,function can be variable(i.e. what do you want the EF to be?)

Cardiac Power (or reserve) = pressure x flowMAP x CO/451 (Left Ventricle)

Finke JACC 2004 44:340

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CS Level 1SBP <90 30 min pre-ionotropes

Pulmonary congestionor

Impaired end-organ perfusion:AMS

Cold/ClammyOliguria

Lactate >2

CS Level 2 (Profound)CS Level 1

CI <2.2 L/min/m or

Lactate > 3Despite

2 Ionotropes/Pressors

CS Level 3 (Deep)CS Level 2

Two of the following:Lactate > 8mmol/l

AnuriaRHF

Escalating PressorsRespiratory Failure

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CS: Hemo-Metabolic Problem (aka “Post-ICEBERG SYNDROME”)

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“More Horsepower”

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Cardiogenic Shock Line : Triggers

CS Level 1SBP <90 30 min pre-ionotropes

tachyPP = 20

PPP (PP/SBP) = 0.2

Pulmonary congestionor

Impaired end-organ perfusion:AMS

Cold/ClammyOliguria (<30cc/hr )

Lactate >2

Make the Call

2x4 RuleLactate 2 = ICU

Lactate 4 = Meds No More

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Changes in Sublingual Microcirculation

IMPROVED END ORGAN PERFUSION WITH PVAD

MCS OFF MCS ON

Lam, et. al., Clin Res Cardiol, 2009,

Baseline prior to Impella support After 48hrs of Impella support

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Percutaneous Left Ventricular Support Devices- Which one?

Werdan et al, EHJ 2014

$ $$ $$

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International Journal of Cardiology, Volume 201, 2015, 684–691

Normal

Drugs

CHF

Impella

ECMO

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4646

Stagnant areas of blood in LV and Ao Root thrombus

LV distention and pulmonary hemorrhageNo recovery of LV

ECMO: No LV decompression

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Important of maintaining residual LV flow

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Timing is Everything

Only 15% with IABP pre PCI

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15%13%

15%

35%

30%

35%

0%

5%

10%

15%

20%

25%

30%

35%

40%

CPR VF/VT arrest Any event

Even

t rat

e (%

)

IABP pre (n=62)IABP post/none (n=57)

Single center registry Primary PCI for shock

Brodie AJC 1999;84:18

Timing is Everything

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Impella 2.5 initiated prior to unprotected left main PCI in acute myocardial infarction complicated by cardiogenic shock improves early survival

Journal of Interventional Cardiology17 APR 2017 DOI: 10.1111/joic.12377http://onlinelibrary.wiley.com/doi/10.1111/joic.12377/full#joic12377-fig-0002

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1.0

0.8

0.6

0.4

0.2

0 5 10 15 20 25 30

Surv

ival

Rat

e

IABP/Inotropes Pre-PCI

Impella Pre - PCI

Days from initiation of Impella

Log-Rank, p=0.004

O’Neill, et. al, J Interven Cardiol, 2014

Timing of Support Impacts Outcomes30 Day Survival

cVAD Registry*N= 154

Door to Balloon Metric - Cardiogenic Shock & hemodynamic support are excluded from Door to Balloon (DTB) metrics Source: CMS, SCAI & ACC *The catheter based VAD Registry is a worldwide, multicenter, IRB approved, monitored clinical registry of all patients at participating sites; registry data is used for FDA PMA submissions

cVAD Registry

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RV

5353

5454

LVPhysically Larger

One jobGets most of the attentionReplaceable with machine

Simple algorithmEasy to understand

5555

LVPhysically Larger

One jobGets most of the attentionReplaceable with machine

Simple algorithmEasy to understand

RVPhysically Smaller

Multiple jobsUnderappreciated

When fails, all hell breaks looseCan’t put a number on it

Understanding is Nuanced

5656

• RV empties when relaxing

• Very sensitive to afterload

• Prolongs isovolumetric timeincreases O2 cost

1 Ejection (opened PV)2 Relaxation3 Close of pulmonic/aortic valve

end of ejection

RV Physiology

5757

RV: Lots of Ways to Fail!

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When to pull the trigger ?

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Impella : Left “Bipella” : Left & Right

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(a few) Predictors of RV failure

CVP / PCWP

MAP/CVP

PAPi (Pulmonary artery pulsatility index) =

RVSWI =

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PASP-PADPRA

(mPAP-CVP) x Stroke Volume Index

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National Shock Initiative: CS with Acute MI

6161

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National Shock Initiative

6363

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Importance of Escalation and Recovery strategies

No RecoveryEscalate (& Ambulate) or Transfer

Guidance by RHC Is Critical

Worsening / not improvingclinical, echocardiographic & hemodynamic parameters (concordant):• ↓ Cardiac output• ↓ CPO• ↓ Urine output• ↑ Lactate, ↓ MVO2• Inotrope dependent• Absent pulsatilityCPO remains < 0.6

After 24 hours

PAPi ≤ 0.9 (RV Failure)

Biventricular supportwith Impella RP® on the right side

(transfer if not available)

RV Failure as defined by Recover Right1:

• CI < 2.2 L/min/m2 (despite continuous infusion of ≥ 1 high dose inotrope, ie, da/dobutamine≥ 10 µg/kg/min or equivalent) and any of the following:1. CVP > 15 mmHg, or 2. CVP/PCWP or LAP ratio >0.63, or3. RV dysfunction on TTE

(TAPSE score ≤14 mm)

0.9 < PAPi ≤ 1.5 (RV dysfunction)

Consider supporting theright side with Impella RP (transfer if not available)

IMP-127-16

CPO = (MAP × CO)/451.PAPi = sPAP - dPAP/RA.Anderson MB, et al. J Heart Lung Transplant. 2015;34(12):1549-1560.

PAPi > 1.5 (acceptable RV function)

Consider left-side escalationwith Impella 5.0™

(transfer if not available)

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Should you pull the trigger ?

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What ICEBERG?