Which mechanical circulatory support should we use as first line option
- 1. Cardiogenic Shock: Which Mechanical Support Should We Use as First Line Option? Mariell Jessup MD FAHA, FACC, FESC Professor of Medicine University of Pennsylvania Philadelphia, Pennsylvania, USA
- 2. Disclosure: Mariell Jessup MD • Speakers Bureau: • Advisory Board: • Honorarium: University of Pennsylvania NONE
- 3. 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.
- 4. Who would benefit from temporary support? üAcute cardiogenic shock Acute myocardial infarction Acute myocarditis Complications post MI Papillary muscle rupture Ventricular septal defect üPost cardiotomy failure üAcute on chronic (end-stage) heart failure üElectrical “storm”, or post-VT ablation üDrug overdose with myocardial depression üHypothermia Windecker S. Curr Opin Crit Care 13:521–527. 2007
- 5. the OPTIONS
- 6. Sick patient Temporary supportChronic support Unclear situation 1. Support circulation 2. Oxygenate patient Choice dictated by clinical status: temporary support ECMO Durable VADs pulsatile non-pulsatile
- 7. Illustrative cartoons are helpful…. but these patients are desperately ill.
- 8. 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?
- 9. ~ 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.
- 11. “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.”
- 12. RV function ?? renal function ?? Especially in the patient with renal failure
- 13. UNOS registry 2000-2010 13,250 patients with first transplant
- 14. 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%.
- 15. 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
- 16. 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 Surgical CentriMag
- 17. 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
- 18. Disadvantages of Percutaneous Devices üBleeding üLimited to left ventricular support (except ECMO) Not for biventricular support Not for RV support (CentriMag can be used) Ventricular arrhythmias üIschemic limb üUnable to mobilize or rehab üSepsis
- 20. 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
- 21. 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
- 22. Impella
- 23. 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
- 24. 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
- 25. Impella: Data the ISAR-SHOCK trial Seyfarth M, Sibbing D., et. al. JACC 2008;52:1584–8 Improved cardiac power index No difference in survival
- 26. Tandem Heart
- 27. Tandem Heart Advantages • Can be placed easily in the catheterization laboratory • Can supply up to 5 l/min flow • Can be easily removed
- 28. Tandem Heart Disadvantages • Requires trans-septal placement • Difficult to place in setting of severe peripheral vascular disease
- 29. 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.
- 30. 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.
- 31. Cheng, JM et al. European Heart J 2009; 30: 2102 30-day mortality
- 32. Cheng, JM et al. European Heart J 2009; 30: 2102
- 34. ECMO - Advantages üCardio-pulmonary bypass üCan be placed peripherally (without thoracotomy) üThe only percutaneous option for biventricular support üThe only option in the setting of lung injury
- 35. ECMO - Disadvantages • Requires trained team and equipment availability on-site and early in resuscitation • Higher risk of infection, bleeding and vascular injury
- 36. 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 MSOFMSOF Neurologic DeficitNeurologic Deficit MCS ExplantMCS Explant Medical TherapyMedical Therapy IABPIABP Revascularization,Revascularization, surgerysurgery Palliative CarePalliative Care RehabilitationRehabilitation Rapid Deterioration (hrs) MCS in Cardiogenic Shock: Management Algorithm Gregoric I, Bermudez C. Braunwald Comp., Mechanical Support 2011 Days -Weeks
- 38. 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
- 39. 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
- 40. Sick patient Temporary supportChronic support Unclear situation 1. Support circulation 2. Oxygenate patient Choice dictated by clinical status: temporary support ECMO Durable VADs pulsatile non-pulsatile
- 41. 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
- 42. Thank You