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Postcardiotomy Cardiogenic
Shock: Optimizing Outcomes
AATS 2012, Adult Cardiac Surgery Symposium
Daniel Goldstein MD FACS FACCAssociate Professor
Vice Chair, Dept. Cardiothoracic Surgery
Disclosures
� Thoratec Inc., Medical Advisory Board
� Terumo, Chair, AEC, DuraHeart BTT Trial
� Berlin Heart Inc., Medical Advisory Board� Berlin Heart Inc., Medical Advisory Board
� Site PI: HW BTT/DT Trials, ROADMAP, REVIVE-
IT
� Will NOT discuss unapproved devices
Goals - PCCS
� Definition, epidemiology, prognosis
� Profile: hemodynamic, pharmacologic, clinical
� IABP: not a VAD� IABP: not a VAD
� Mechanical support options: what, how, when
� PCCS in community: How can you optimize
patient for transfer to VAD/Transplant center?
Limitations
� Infrequent (0.2-3%), heterogenous patients,
mutliple technologies
� Most of the literature is single center, � Most of the literature is single center,
retrospective, small # pts
� Few multicenter studies, small #s
� No randomized data for PCCS
� Consensus opinion from experts
Postcardiotomy Shock Definition
� Non standardized:
� Inability to wean from CPB, or
� Marginal hemodynamics in OR, or � Marginal hemodynamics in OR, or
� Dvlpmt of poor hemodynamics in early postop period
� CI < 2 l/min/m2, SBP < 90 mmHg, high filling
pressures and MVO2 < 60 despite adequate Hgb and
pharmacologic support
Postcardiotomy Situations
� Low EF CABG/MV
� Low EF MV
� Low EF CABG/poor targets� Low EF CABG/poor targets
� CABG post acute MI/CS
� RHF after transplant or LVAD
� CABG/post infarct VSD
� CABG/post infarct MR
Goals of Postcardiotomy Assist
� Unload injured ventricle(s)
� Wean toxic level of pressors
� Maintain end-organ perfusion/function� Maintain end-organ perfusion/function
� Allow cytokines to be metabolized
� Allow replenishment of ATP stores
� Allow myocardium to declare recoverability
PCCS: The Typical Story=.
� Difficult operation, failure to wean
� Rest on CPB:
� Optimize pacing, Hct, ABG
� Check TEE for new WMAs, residual valve leaks
� Check graft flows
1-2 hrs
Addtl � Check graft flows
� Escalation of inotropes / pressors
� Reattempt CPB wean
� IABP=you fail again=.
Addtl
CPB !
NOW you consider mechanical support=.coagulopathy,
oliguria, transfusions, hypoxia, pulm HTN, RHF=..
Intra Aortic Balloon Pump = VAD
AdvantagesAdvantagesAfterload ReductionAfterload Reduction
Enhances Coronary PerfusionEnhances Coronary Perfusion
Easily InsertedEasily Inserted
Easily RemovedEasily RemovedEasily RemovedEasily Removed
CheapCheap
DisadvantagesDisadvantages
Limited UnloadingLimited Unloading
≤ 10% Power Increase≤ 10% Power Increase
? Benefit in Non? Benefit in Non--Ischemic SyndromesIschemic Syndromes
IABP Mortality in PCCSIABP Mortality in PCCS
30
35
40
45
50
% Mortality
0
5
10
15
20
25
30
THI SLU Methodist Duke Wash. U
% Mortality
IABP MortalityIABP MortalityWhy so high ?
�� IABP requires stressed heart to continue to IABP requires stressed heart to continue to
expend energyexpend energy
�� The afterload reducing effect < increased The afterload reducing effect < increased �� The afterload reducing effect < increased The afterload reducing effect < increased
myocardial Omyocardial O22 demands of inotropic supportdemands of inotropic support
�� Because IABP benefit is limited, profoundly Because IABP benefit is limited, profoundly
insulted heart may be unable to maintain endinsulted heart may be unable to maintain end--
organ perfusionorgan perfusion
Probability of Death: Postoperative Inotropic Probability of Death: Postoperative Inotropic
SupportSupport
Allegheny University Hospital, Hahnemann DivisionAllegheny University Hospital, Hahnemann Division
100%100%
90%90%
80%80%
70%70%
Probability of death (%)
Probability of death (%)
70%70%
60%60%
50%50%
40%40%
30%30%
20%20%
10%10%
0%0%
No doseNo dose Low doseLow dose Moderate doseModerate dose One high doseOne high dose Two high doseTwo high dose Three or more Three or more
high dosehigh dose
Probability of death (%)
Probability of death (%)
Samuels LE. J Card Surg 1999;14:288-93
Hemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic Criteria
Hemodynamic:
�BP < 90mmHg (systolic)
�CVP > 15mmHg (mean)
�PAP > 40mmHg (systolic)
�CI < 2.0 L/min/m2�CI < 2.0 L/min/m2
Pharmacologic:
�Epinephrine > 10 mcg/min
�Dopamine > 10 mcg/kg/min
�Dobutamine > 10 mcg/kg/min
�Milrinone > 0.50 mcg/kg/min
Samuels LE. J Card Surg 1999;14:288-93
ABIOMEDABIOMEDBenefit of Early ImplantationBenefit of Early Implantation
30
35
40
0
5
10
15
20
25
30
< 24 Hrs > 24 Hrs
% Weaned
What’s On the Shelf?
Mechanical Options
� Centrifugal Flow Pumps (Biopump, CAPIOX,
Sarns)
� Routine use for CPB
� Short term support
� May be used for ECMO
� Blade, impellers or cones provide momentum creating
high flow at low pressures
� Single moving part, disposable, cheap
� No data supporting superiority of design
Centrifugal Flow Pumps
Mechanical Options
� Extracorporeal Pumps:
� AB5000
� Pulsatile, paracorporeal, portable, pneumatic
� More complex (grafts to Ao, PA)
� Expensive� Expensive
� Versatile
Registry Data (STS)
Most Recent Data
� Survey of all cardiac centers in UK (67)� Survey of all cardiac centers in UK (67)
� 10/07 - 10/08: 28,000 pts, 66 pts underwent VAD for PCCS
� Outcomes
41% d/c home (recovered)
42.5% died on support
16.5% died after successful wean
� Drastic improvement from prior decade (75% mortality)
Mechanical Options
� “New” Technologies
� Percutaneous extracorporeal
� TandemHeart� TandemHeart
� Third Generation Continuous Flow pump
� Centrimag
� Microaxial Flow pump
� Impella system
TandemHeart
� Most versatile system
� Centrifugal pump
� Transseptal LA cannula
PercutaneousPump
� Transseptal LA cannula
� Works with any cannula
� Expensive
� “Purse-string” placement
� Easy for IH transfer
BiVAD ± ECMOController
CentriMag
� Versatile system
� Mag-Lev
� Less hemolysis
� Works with any cannula
Pump
� Works with any cannula
� Expensive
� “Purse-string” placement
� Easy for IH transfer
Console
IMPELLA
� TEE guided transaortic placement
� Through graft sewn to aorta
� No AV injury or AI
� Expensive
� Quick to place
� No RV support; AI, mech valve C/I
� 16 pts with PCCS, 6 hospitals
� 1 high dose or 2 mod dose pressors ± IABP� 1 high dose or 2 mod dose pressors ± IABP
� Mean flow 4 lts/min
� Mean support 3.7 days
� 94% 30d survival
Mechanical Options
� ECMO� Resurgence for all shock etiologies due to cost, mini-, ease of deployment
� Not a “system” but a modality of support� Not a “system” but a modality of support
� Familiarity
� Miniaturized circuits
� Less forgiving with anticoagulation than newer systems
� Doable with all previous systems except Impella, AB5000
� Good for transfer
NO!
PCCS Strategy
� In high risk situations, place femoral line preop
� Insert IABP prior to weaning high risk cases
� Wean CPB (2 Ino/pr); If CI < 2 l/min/m2, filling
pressures are high, and MVO2 less than 60% pressures are high, and MVO2 less than 60%
(with adequate Hct), institute mechanical support
� Do NOT leave OR struggling with hemodynamics
What to Insert: LVAD vs BiVAD
�� Once left heart support in place, observe RV for few Once left heart support in place, observe RV for few
mins:mins:
�� CVPCVP
�� TR (TEE)TR (TEE)
�� LVAD fillingLVAD filling�� LVAD fillingLVAD filling
�� Use pulmonary vasodilators (mil, dob, iNO)Use pulmonary vasodilators (mil, dob, iNO)
�� RV function should improve with LV unloadRV function should improve with LV unload
�� In general, if CVP >16 on inotropic support, place RVADIn general, if CVP >16 on inotropic support, place RVAD
�� When in doubt, BiVAD: RAWhen in doubt, BiVAD: RA--PA, LA/LVPA, LA/LV--AoAo
�� Use ultrafiltration aggressivelyUse ultrafiltration aggressively
�� Reexplore for bleeding earlyReexplore for bleeding early
In ICUF.In ICUF.
�� Have explicit anticoagulation protocolsHave explicit anticoagulation protocols
�� Heart & endHeart & end--organs must have recovered before organs must have recovered before considering weanconsidering wean
�� Reach out to VAD/Txp program early (hub and Reach out to VAD/Txp program early (hub and spoke)spoke)
Not a Good Transfer !!
InterInter--Hospital TransferHospital Transfer
�� Neurologically intactNeurologically intact
�� Not hemorrhaging, on heparinNot hemorrhaging, on heparin
�� Preferably, closed chestPreferably, closed chest�� Preferably, closed chestPreferably, closed chest
�� Not anuricNot anuric
�� Not septicNot septic
�� Transplant/LVAD considerationsTransplant/LVAD considerations
�� Insured or insurableInsured or insurable
Keys to SuccessKeys to Success
�� No device superiority No device superiority -- get comfortable with get comfortable with one systemone system
�� Insert early !!Insert early !!
�� Survival approaches 50% with insertion within 60 Survival approaches 50% with insertion within 60 minutes of first attempt to weanminutes of first attempt to wean
�� Early insertion minimizes complications of Early insertion minimizes complications of prolonged CPBprolonged CPB
�� Consider biventricular supportConsider biventricular support
�� Right heart failure can be swift and fatal Right heart failure can be swift and fatal -- when in when in doubt, support the right heartdoubt, support the right heart
Conclusions
� Recent registry data suggests improvements in PCCS morbidity & mortality
� Likely result of:� Likely result of:
� Earlier institution of support
� Better technology
� Improved ICU care
� Establishment of hub-spoke relationships
Recommended