Prise en charge du choc cardiogénique post-infarctus- CI < 2.2 L/min/m2 (by echocardiography...

Priseenchargeduchoccardiogéniquepost-infarctus

Bordeaux–05.02.2019

DrC.Delmas

USIC-CHUToulouseRangueil

frenshock@sfcardio.fr/delmas.clement@chu-toulouse.fr

PhysiopathologyofCS

UsualCSphysiopathology

• Systolicdysfunction

VanDiepen.Setal,AHACSRecommandations,Circulation2017

•  Diastolicdysfunction

•  SIRS

ArjolaVP.EurJHeartFailure2018

CSphysiopathology:anevolvingconcept

•  Lowcardiacoutput•  Pulmonary,renalandliver

congestion•  Inflammation/vasoplegia

Organmalfunctionbymalperfusionandcongestion

DifferentclinicalpresentationofCS

VanDiepen.Setal,AHACSRecommandations,Circulation2017

Limitsofusualdefinition

Definition/Diagnosis/Monitoring

CSdiagnosis=classicCSdefinition

VanDiepen.S,CirculationSept2017

UsualdefinitionaremainlyaboutischemicCSandleftventricularfailureCS

Maymissedpre-Shockanddelayedtreatment/supports

CSconcept:evolutionandprogression

Bellumkonda.Letal,AmJCardiol2018

1-Lowcardiacoutputcriteria -SBP<90mmHgorneedvasopressors/inotropstomaintainSBP>90mmHg

-CI<2.2L/min/m2(byechocardiographyand/orinvasivehemodynamicevaluationwithrightheartcatheterization)

2-Rightand/orleftoverloadsignscriteria -Clinical(dyspnea,ralesandcrepitations,jugularvenousdistensionand/orabdomino-jugulartest,edema,…) -Biology(Nt-proBNP>900pg/mland/orBNP>400pg/ml) -Radiology(overloadsignsonchestrayand/orchesttomodensitometry)

-Echocardiography(E/A>2ifLVEF<45%orE/Ea>13ifLVEFwasnormal;orsPAP>35mmHg,and/orEdecelerationtime<150msand/orAp-Am>30msand/orE/Vp≥2,5)

-Invasivehemodynamicevaluationwithrightheartcatheterization(PCWP>15mmHgand/ormPAP>25mmHg)

3-Organmalperfusioncriteria -Clinical(oliguria<0.5ml/kg/h,confusion,cold/clammyskinandextremities,and/ormarbling) -Biology(lactate>2mmol/L,metabolicacidosis,liverinsufficiencyand/orrenalfailure)

Tobeconsideredasacardiogenicshock,patientmustfulfillatleastonecriterionofeachofthe3

components:lowcardiacoutput+leftand/orrightoverload+sign(s)oforganmalperfusion

Asimpleandeasydefinition=FRENSHOCK

Nodifferenceintermsofearlyoutcomesbetweenpatientswithorwithouthypotension

FRENSHOCK772patientsin49centersFrance6months2016 Patientswith(ESC-HF=1),orwithout(ESC-HF=0)hypotension

Allwithlowcardiacoutput,overloadsignsandorganmalperfusion

Delmas.Cetal,JESFC2019

Price.Setal,NatureReviewinCardiology2017

ReynoldsHR.Circ2008

Frenshock

Cardshock

IABPShock2

PlaceofTTE:heartsystolicfunction

evaluation

ArjolaVP.EurJHeartFailure2018

AdaptedbyG.Leurent

Ibanez.Betal,EurHeartJ2017

Limitsandinsufficiency

ofLVEFevaluation!

PlaceofTTE:heartdiastolicfunction

evaluation

ArjolaVP.EurJHeartFailure2018

17%

Lancellotti.Petal,EurJCardiovascImaging2017

Sensibility75%/Specificity74%PPV39%/NPV93%

Placeofinvasivehemodynamicevaluation?

Ibanez.Betal,EurHeartJ2017

Cecconi.Metal,IntCareMed2014

v

v

v

•  Notsystematic?•  IncaseofRVdysfunction•  Incaseofmixedshock

•  Incaseoftreatmentfailure

•  Managementmonitoring

Mebazaa.Aetal,IntCareMed2018

EpidemiologyanddescriptionofischemicCS

IschemicCS=themainetiology!

• IschemicCS:• Mainetiology(36%inFRENSHOCKregistry)

ShahMetal.ClinResCardiol2017

•  OthersCS:Morefrequent•  Dilatedcardiopathy.terminal

HF.obstructivecardiopathy.myocarditis.intoxication.valvulopathy.PE.takotsubo.sepsis.…

Delmas.Cetal,inreviewing2019

IschemicCSincidence

↗prevalenceinICU:•  4.4%en1997-2000•  7.7%en2009-2012

Puymirat.Eetal,DatasCubRéa,EJHF2016

Goldbergetal,Circulation2009

Incidence≈stablesince20years

–  5to8%STEMI– 2.5%N-STEMI

=60-70000cas/yearinEurope Thiele.Hetal.,EHJ2010

CCmorefrequentincaseofSTEMI

DeLucaLetal,EJHF2015 28217patientswithACSand526withischemic-CS

X1.5to2

CSmorefrequentinwomen

Puymirat.Eetal,ArchCardiovascDiseases2017

10000patientswithACS(FASTMI1995-2000-2005-2010

X1.5to2

CSismorefrequentwithage

AissaouiNetal,EurJHeartFail2016

P=0.023 P=0.019

P=0.012

10000patientswithACS(FASTMI1995-2000-20005-2010

CS:2temporalpresentation

AwadHHetal,AmHeartJ2012

Ischemic

AllCS

-  24%CCàl’admission-  62%aucoursdes241èresh-  14%aucoursdel’hospitalisationaprès24h

HarjolaVPetal,EHFJ2015

22,3%àl’admission

GRACE CARDSHOCK

CSprognosis

EvolutionoftheischemicCSprognosis

Kunadianetal,JACCCardiovascInterv2014

Raban.V.Jaegeretal,AnnInternMed2008

Aclinicalchallengewithhighmortalityrates

MoresevereprognosisincaseofischemicCS?

HarjolaVPetal,EHFJ2015

•  CardSHOCK•  Multicentricprospectiveregistry(9europeancenters)

•  219patients=ACS177(rouge)et42NonACS(bleu)

IschemicCSprognosisprediction:IABPShock2score

•  Easycriteria=incathlab•  Recentcohorts:IABPshockstudy+validationbyIABPregistryandCardShock

Poss.Jetal,JACC2017

TherapeuticmanagementinischemicCS

-Revascularization-Cardio-vasoactiveagents

Highandearlymortality:activemanagement+++

• Highmortalityduringthefirst48h

• Prognosisseemsgoodafter

Kunadianetal,JACCCardiovascIntervention2014

Aissaouietal,CritCareMed2014

Placeofearlydiagnosis+

stratification+treatement

>40%in-hospitalmortality

2.InotropsDobutamine

1.Reperfusion

3.VasopressorsNoradrénaline

ESC 2014 = Classe IB ESC 2016 = Classe IB ESC 2017 = Classe IB

ESC 2017 = Classe IIbC ESC 2016 = Classe IIaC SRLF = strong agreement

CS:Physiopathologyandtherapeuticsapproaches

DelmasCetal,Réanimation2017

ESC 2017 = Classe IIbC ESC 2016 = Classe IIaB SRLF 2015 = strong agreement

Centralplaceofrevascularization++++

AissaouiNetal,EHJ2012

Bangaloreetal,AmJMedecine2015

Ibanez.Betal,

2017ESC

Guidelines,Eur

HeartJ2017

Invasivestrategy=coro+/-revascularization

Bangaloreetal,AmJMedecine2015

IschemicCS:invasivemanagement

strategy

KolteD,AmJCardiol2016

STEMI

N-STEMI

Extentofatherosclerosisinpatientswithcardiogenicshock

Hochman,JSetal.NEJM1999Baumgartetal.,1993

HeushBritishJournalofPharmacology2008

Immediatecompleterevascularization?

ThieleHetal,NEJM2017

•  CULPRITSHOCK

•  Multicentriquerandomiséeprospectiveeuropéenne(706patients)

DeathorRRT

Differentclinicalpresentations=differenttherapeuticapproaches!!

VanDiepen.Setal,AHACSRecommandations,Circulation2017

§  Fluidchallenge?§  Inotrops?

§  Diuretics?§  Inotrops?§  Vasopressors?

§  Diuretics?§  Inotrops?§  Vasopressors?

WhataboutchronicHFtreatment?

Mebazaa et al, EHJHF 2015 Farmakis.D et al, Int J Card 2015

PonikowskiPetal,ESCHFguidelines,EHJ2016

Cardiogenicshock=stopusual

chronicHFtreatment

1.   Norepinephrineshouldbeusedtorestoreperfusionpressureduringcardiogenicshock(strongagreement)

2.   Dobutamineshouldbeusedtotreatlowcardiacoutputincardiogenicshock(strongagreement)

3.  Phosphodiesteraseinhibitorsorlevosimendanshouldnotbeusedfirstline(strongagreement)

4.  CSrefractorytocatecholaminescanbetreatedbyperfusionofphosphodiesteraseinhibitorsorlevosimendan

5.  Thereisapharmacodynamicrationalefortheuseoflevosimendaninpatientson

chronicbeta-blockertreatment

Levyetal,AnnalsofIntensiveCare(2015)

Norepinephrinefirst!

Nad=égalementuneffetinotrope+

Beurton.Aetal,Shock2014

Effetsvasculairesα>actionβ1

DonotuseEpinephrineinCS

Leopold.Vetal,IntensiveCareMed2018

•  Métaanalysede2583patients•  12cohortes+3étudesrandomisées

Mortalitéx3

9Frenchcentersbetween2011-2016ACSCSrevascularized+Swan-Ganz

Levy.Betal,JAmCollCardiol2018

Whatperfusiontargets?

•  Améliorationperfusiond’organes

•  Améliorationperfusionmyocarde

•  AugmentationdelaMVO2etIschémie

•  AugmentationpostchargeVG

•  SurchargecalciqueetArrythmies

Ø Cliniques:marbrure,conscience,diurèse+++Ø Lactate,biohépatiqueetrénaleØ SVO2>65-70%

Ø NadpourPAM>65(voir70mmHg?)Ø InotropespourIC≥2,2-2,5L/Min/m2

QSP

Commentadapterlesamines?

Monitoring++++

VanDiepen.Setal,AHACSRecommandations,Circulation2017

•  Tenterrégulièrementlesevragechezlespatientsstabilisés

•  Savoirimplémentersiinsuffisant

SamuelsLEetal,JCardSurg.1999

Highmortalitydespiteoptmalmedicalmanagement:placeforcirculatory

support?

MortalityRiskwithInotropes/

VasopressorsN=3462

Conventionaltreatmentlimits(1)

Conventionaltreatmentlimits(2)

Thiele.Hetal.,EurheartJ2015

Placefor(cardio)-circulatorysupport?

Supportcirculatoire

(perfusiond’organe)

Décharge

ventriculairePerfusioncoronaire

+ +

PAM PTDVG PAM-PTDVG

KapurNKetal,Eurointervention2016

HCS-PMA-PP01224-027rA

Determinantsofthehemodynamicsupport

Objectifs:Mettrelecœuraurepospourfavoriserlarécupération

EtEviteroucorrigerladéfaillancemultiviscérale

Whentothinkabout(cardio-)circulatorysupport?

Yoshiocaetal,CircJ2012

PlaceforINTERMACSclassification

CardiogenicShock

Bridge to recovery

Bridge to transplantation

Bridge to bridge

Assistance

DiscussionbeforeMCSimplantation:shockTeam+++++++Moyenshumains,matériels,financiers…Questionéthique

Death Bridge to decision

Forwhichpatient’sproject?

CentralplaceforTTEevaluation:LVandRVfunction,mechanicalcomplication,valvedysfunction,…

VitarelliA,HeartFailRev.2010

Which

thresholds?Ibanez.Betal,EurHeartJ2017

• Anavailableandknownsupport• Asupportadaptedateachclinicalsituation

Thieleetal,EHJ2015

WhattypeofsupportinacuteCS?

1970 19902000 2004-2005 2015

IABPplaceinischemicCS?

30days

12months

Thiele.Hetal,NEJM2012

Thiele.Hetal,Lancet2013

Nodifférencevs

medical

treatment!!

IABP-SHOCK II

Axillaire

Fémoral*

Mini sterno

IMPELLA:3devices

•  Assistancemono-ventriculairegauche•  Pompeaxialerotative(20-50000trs/min)•  PlacéeàtraverslaVao•  2typesdepompes:

•  Abordpercutané

•  Impella2.5(12Fr;5j)•  ImpellaCPou3.5(14Fr;5j)

•  AbordChirurgical

•  Impella5.0(21Fr;10j)=tubeendacron

HemodynamicandclinicaleffectsofImpella

BasirMetal,AmJCardiol2017

SaurenLD,Artiforgans2007;MeynsBJACC2003;RemmelinkMCatheterCardiovascInterv2007;AgelRA,JNuclCardiol2009;

LamKClinResCardiol2009

Impella=acuteLVassistdevice

•  RealLVunloading//Nooxygenationanddecarboxylation•  GradualLV-Aopressuregradientdecoupling=Impellasupport

Uriel.N,JACC2018/Burkhoff.Detal,JACC2015

ClassIIb

CIbanezetal,EHJ2017

Ponikowskyetal,EHJ2016

WhichsupportinCSpatients:Impella2.5,CPor5.0?

Impella5.0(surgical)orImpella

CP(percutaneous)>>2.5

EngstromAEetal.,CritCareMed2011

O’Neill.WWetal,AmJCardiol2018

Thiele.HetalEHJ2017

Randomizeddatas?:ClinicaleffectsofMCSvsIABP

IMPRESSstudy:gapsandlimitsVeryseverepatients:

•  100vs83%priorCA•  100%ETIandMV•  100%vs92%underinotrops•  Traumaticlesion=21%vs8%•  Lactates7.5vs8.9mmol/l•  pH7.14vs7.17

Nonoptimalmanagement

•  21vs13%beforePCI•  Timeundersupport49vs48h

Crossover:•  4.2vs12.5%

Conclusion:ForpostCACSduringACS,ImpellaCPisnotbetterthan

IABP

Ouweneel.DMetal,JACC2016

ProspectivestudiestoevaluatetheefficacyofImpellainischemiccardiogenicshock

LackofrandomizeddatasinCSpatients!

DelmasCetal,ACVD2017

O’Neill.WWetal,AmJCardiol2018

USdata:Experienceroleandlearningcurve

•  Real-lifepracticeinUS•  15259CSpatients•  Age63.5(+/-12.3)•  Male73%

§  Impella2.5(33%)–CP(61%)–5,0(5,2%)§  Impellapre-PCI48%§  Durationofsupport3,78+/-4,8

USdata:whentoimplant?

BeforePCIincaseofischemicCS

ONeill.WW,JIntervCardiol2014

BasirMetal,AmJCardiol2017

•  cVADregistry=287patientswithischemicCS

•  Layingtime=17min

USdata:whentoimplant?

Assoonaspossible

BasirMetal,AmJCardiol2017

3groups(<1.25h,1.25–4.25h,>4.25h)

Correlationbetweenmortalityandnumberofinotrops

Beforeinotropsincaseof

ischemicCS??

Inhospital

survival

Inhospital

survival

O’Neill.WWetal,AmJCardiol2018

•  Real-lifepracticeinUS•  15259patients•  Age63,5(+/-12,3)•  Male73%

•  Impella2,5(33%)–CP(61%)–5,0(5,2%)

•  Impellapre-PCI48%

•  Durationofsupport3,78+/-4,8

USdata:whentoimplant?

Flaherty.MPetal,JACC2017

But…..

•  237patientsEUROSHOCKregistrymatchedwith237patientsfromIABPShock2study

Schrage.Betal,Circulation2018

And:Significantcostgenerated…

•  Netincreaseinspendingwithincreasingtheiruse

•  Noformalmortalitygaindemonstratedtodate

Reyentovich.Aetal,Nature

Review2016

Shah.Aetal,JInvasiveCardiol2015

RepaymentfilesbeinganalyzedinFrance...

Uriel.N,JACC2018

ConceptofLVunloading Objective:1.  ProvideasufficientflowtolimitMOFand

death=savethepatient2.  Reducereperfusioninjuryinordertolimit

myocardialinfarctsizeandlimittheprogressiontoHF=savetheheart

JACCHF

2015 JACC2018

VA-ECMO=Circulatorysupport

•  ECMO=circulatoryandrespiratorysupport

•  ECMO≠cardiacsupport

•  NoLVunloading=LVnotatrest

Burkhoff.Detal,JACC2015ClassIIbC

IbanezPetal,EHJ2017;Ponikowskyetal,EHJ2016

Pavasini.Retal,CritCareMed2017

Observational16studies/739patients8to138patients/study

VA-ECMO:resultsinmiscelaneousCS

OuweneelDMetal,IntCareMed2016

•  Frequentseriesandregistries•  Norandomizeddatatodate(ANCHORtoujoursenattente…)

MainissuesonVA-ECMOsupport

LVunloadingpromotingrecovery(LV

wallstress,strokeworkandmyocardialoxygenconsumption)

Savetheheart

§  ECMOweaning§  PreventHF

FlowdeliverypromotingorganperfusionandMOF

correction

Savethepatient

§  Stabilizethepatient

IssuescouldbeoppositeunderECMOsupportinCS=>placeofLVunloading?

WHY?LVoverloadisassociatedwithaworseprognosis

•  LVD++(n=9)=clinical•  LVD+(n=27)=subclinical

LVD•  LVD-(n=85)=nosignsof

LVD

Truby.LKetalASAIOJ2017

CorstiaanA.denUiletal,EurJHeartFail2017

•  Lactateatimplantation8,4•  AMI-CS20%,ADCHF14%,Acute

nonMICS25%,postcardiotomy17%,PE16%,…

132ECMO:34LV;29RVet69BiV

HOW?:WhattypeofLVunloading?

Meani.Petal,EurJHeartFail2017

Vallabhajosyula.S,CircCardiovascularInterv2018

•  22studies=4653patients•  Noeffectonshorttermmortality

forthewholecohort•  Significantlowermortalityfor

AMICS(RR0.56(0.46-0.67);p<0.001)

•  Frequentcomplications+++:transfusion(15-89%),limbischemia(10-37%),…

AMI-CS

•  157ECMO=34ECMO+Impellaand123ECMOalonethenpropensityscorematching

•  64%withpriorCPR;54%STEMI;lactates>9Pappalardo.Fetal,EJHF2017

Patel.SMetal,ASAIOJ2019

Better30-daysand1-yearsurvival

Rapiddeclinein

inotropsuse

Samecomplications

SurgicalLVventing

CanuleapicaleVGparthoracotomiegauchesousETO

Canulesous-clavièreintraVGtrans-aortiquesousscopie

•  Canuleveines-pulmonairesparthoracotomiedroiteousternotomie

•  Canulesdansl’AP•  …

Circuitveineuxdel’ECMO

Balloonatrialseptostomy:fewdatasavailable

•  Right-leftshuntbyinteratrialseptumopening

•  Complications?/PersistenceofaremoteIAC?

Baruteau.AEetal,EurHeartJACC2018

Bellumkonda.Letal,AmJCardiol2018

1.   InitialseverityofCS•  MOF

•  RVfunction

•  Respiratorystatus

3.   Localexperiencesandcapacities(vascular

and/orcardiothoracic

surgery?)

Thieleetal,EHJ2015

2.   Availabledevice

AcuteMCS:VA-ECMOvsImpelladevice?

Adaptationofcaretothespecificsituation

Notanisolatedbutaglobalstrategy

Montpellier

Mourad.Metal,ASAIO2017

Whatrecommendationsfor

(cardio)-circulatorysupportinCS?

Desniveauxderecommandationsdefaibleniveaumaisquiseprécisent…

DelmasC,Réanimation2017

CSmanagementalgorithm:Protocols+++

Mebazaa.Aetal,IntCareMed2018

Timetotherapy++

+

Earlydiagnosis

and

management

Managementina

specializedteam

MCSifnecessary

Butaslowevolutionofpractices…

ShahMetal,ClinResCardiol2017

•  Cost•  Eduction/

Training•  Habits

USdatas

Butaslowevolutionofpractices… French

datas

Helleu.Betal,ArchCardiovascDiseases2018

172patientsinamulticentre(19frenchcenters)prospectiveregistryin2015

62%

VariationinMechanicalCirculatorySupportUse

StromCircCardiovascInterv.2019

Shaefi.Setal,JAmHeartAssoc2015

533179hospitalizationsforCSin2675hospitalsbetween2004and2011

Expertscenters?

TchantchaleishviliJAMASurgery2015 RabJAmCollCardiol.2018

Placeofaspecializedmultidisciplinaryteam

CSHeartTeam+++

IntCareMed2018

AllischemicCSpatientsshouldbetransferredinexperts/tertiarycenters??

In-hospitalmortalityofpercutaneouscoronaryintervention-

treatedST-segmentelevationmyocardialinfarctionpatientsby

contact-to-balloontime

Scholz Eur Heart J 2018

But

VanDiepen.Setal,CirculationSept2017

ThefirstclearnationalpositionpaperonMCSinCS

ImplementationofCS

managementorganization

Newapproach:«reducetimetosupport»

Bonello.Letal,ArchCardiovascDiseases2017

Abrams.Detal,IntCareMed2018

•  DifferentapproachbetweenACSCSandnonACSCS

•  Newandclearposition•  EarlierMCS

implantationincaseof

ACSCS=prePCIImpella

CP

•  IncaseofrefractoryCS=implementationbyImpella5.0orVA-ECMO

ACSCS

Contexte / comorbidité LVAD ? TRANSPLANTATION ? •  Troubles psychiatriques; manque de support social; non compliance Peu probable Peu probable •  Maladie artérielle périphérique sévère Peu probable Peu probable •  HTAP fixée (RAP>6 UW) Peu probable Peu probable •  Dysfonction pulmonaire et/ou hépatique sévère - Défaillance multi-viscérale Peu probable Peu probable •  Diabète non équilibré avec retentissement viscéral Peu probable Peu probable •  IC « non systolique » – Petit VG Peu probable Possible •  Défaillance cardiaque droite sévère Peu probable Possible •  Déficit neurologique gênant le maniement du matériel – ATCD d’AVC Peu probable Possible •  Haut risque chirurgical pour l'implantation Peu probable Possible •  Age > 65 ans Possible Peu probable •  Obésité IMC > 35 Cas par cas Peu probable •  Sepsis ou infection active non contrôlée Peu probable Cas par cas •  Coagulopathie sévère (TIH, thrombopénie, saignement actif) Peu probable Cas par cas •  Rein à DFG<40 chronique Au cas par cas Peu probable

Istherealongtermproject?

IspredictingCSoccurencemayimproveoutcomes?

-  STEMImanagedbyprimaryPCI-  Derivationcohort:6838

patients(ORBI)-  Validationcohort:2208

patients(RICO)

→Predictivescoreofin-hospitalCSoccurence

Auffret.Vetal,EurHeartJ2018

Personalizedcare?

Surveillance USIC brève ?

Transfert USIC III? Assistance prophylactique?

CourtesyofG.Leurent

IschemicCardiogenicShock:Conclusion

• Frequent:MainetiologyofCS

• Needarapidandmultiparametricdiagnosis

• Management:•  Earlyrevascularization•  Fluidmanagment•  Inotrops(Dobutamin)and(Vasopressors(Norepinephrin)•  (Cardio-)circulatorysupportifnecessary

•  LVunloading=EarlyImpellaplacement(?)

• Localandregionalprotocols+++• PlaceofNetworkandCSHeartteam

Priseenchargeduchoc

cardiogéniquepost-infarctus

frenshock@sfcardio.fr/delmas.clement@chu-toulouse.fr