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ShortTermMechanicalCirculatorySupportforAdvancedCardiogenic

ShockChristopherK.GordonMSN,ACNP-BC

Disclosures

• Ihavenodisclosurestoreport

Objectives

1. Pathophysiology2. Epidemiology3. Assessment4. Management

1. Medical2. Mechanical

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HeartFailure

• Aconditioninwhichthereisinsufficientcardiacoutputtomeetthemetabolicdemandsofthebody.

• Canbecausedbyavarietyofconditionsthatdecreasetheabilityoftheheartmuscletopumpblood;eitherbydamagingand/oroverloading

HeartFailure

• Estimated5.7millionpeopleintheUnitedStateshaveheartfailure.

• HeartFailureexpectedtoincreaseto>8millionby2030.

• AcuteCoronarySyndromeaffectingnearly700,000peopleannually

• Oneofthemostfrequentcausesofunscheduledhospitaladmissions

Eargle,K.,Ochsner Journal, 16:243-249.2016

HeartFailure

• Dividedintomultiplesub-categories

• Leftsided• Rightsided• Bi-Ventricular

• Systolic• Diastolic

• Acute• Chronic• AcuteonChronic

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AcuteHeartFailure(AHF)

• Canoccurwitheitherimpairedorpreservedejectionfraction

• Heartfailureiscategorizedasaheartdisorderbutcanleadtoasystemicdisorderaffectingallvitalorgans

• Mechanismsofdysfunction:– Congestionandhypo-perfusion

ManagementofAHF

• Needstobeefficient,rapidandorganized• MultidisciplinaryCare:– Intensivists,HeartFailureCardiologist,InterventionalCardiologist,CardiacSurgeon,Advancepracticeprovider,Nurse,Respiratorytherapist

• Goalsofcare– RestoringCardiacOutput– Identifyingandtreatingtheetiology

ClinicalPresentationofAHF• Importanceofphysicalexam

• JugularVeinDistension(JVD)

• Hepatomegaly• PeripheralEdema• Tachypnea• Rales• Orthopnea• Gallops(S3)

• HeartMurmurs• Tachycardia• Pulsus alternans• CoolExtremities• Restlessnessand/orconfusion

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DiagnosticEvaluation• Bloodlaboratorytests:– Brainnatriureticpeptide(BNP)

– Troponins– RenalFunction– LiverFunction– Lacticacid– Bloodgasanalysis

• Studies:– Electrocardiogram(ECG)

– Echocardiogram– ChestX-rays– Earlycardiaccatheterization• Ifindicated

HemodynamicProfile

Warm&Wet

• Diuretics– LoopDiureticsaretypicalfirstline• Furosemidebolus(0.5mg/kg)

– ThiazideDiuretics,combinationtherapyor2nd line• Diuril 250mgto500mgIVbolus

• Vasodilators– Nitrates• Nitroglycerin(10-20mcg/min,upto200mcg/min)• Nitroprusside(0.3mcg/kg/min,upto5mcg/kg/min)

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Warm&Wet• Oxygen– Oftenneededsecondarytohypoxiarelatedtopulmonaryedema

• UseofNonInvasiveVentilation– Pulmonaryedemaoftentimescanrapidlyprogress

• Duetofloodingofthealveolisecondarytoincreaseinhydrostaticcapillarypressurewiththelung

• Morphine– Opiatethatcanhelpwithanxietyrelatedtoairhunger– Canleadtoincreasedratesofintubation

Cold&WetCardiogenicShock

• Clinicallypresentsashypotensionwithevidenceoforganhypo-perfusion– AlteredMentalStatus– Cold,clammyskinand/orextremities(mottling)– Oliguria(<0.5ml/kg/hr or<30ml/hr)– Respiratorydistressintheformofpulmonarycongestion

CardiogenicShock

• Themostsevereformofacuteheartfailure• Commonlyadirectsequelaeofacutecoronarysyndrome– Complicating~5%-8%ofacutemyocardialinfarctions

• Non-ischemicEtiologieslesscommon(1%)– Acuteonchronicdecompensations– Myocarditis– Takotsubo cardiomyopathy– Acutevalvular disease

Eargle,K.,Ochsner Journal, 16:243-249.2016

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CardiogenicShock

• Hemodynamicallydefinedas:– Persistenthypotensionwithsystolicbloodpressure<90mmHgormeanarterialbloodpressure30mmHgbelowbaseline

– InadequateCardiacOutput/CardiacIndex(CI<2.2L/min/m2)despitenormalorelevatedpre-load• Pulmonarycapillarywedgepressure>or=to18mmHg• Centralvenouspressure>or=to10mmHg

MedicalManagement

• GoalistorestoreCardiacOutputandreverseend-organdysfunction

• HemodynamicEvaluation• Echocardiograms• Arterialline• SerialLabs

• Lacticacid• Bloodgases• Liverfunction• Renalfunction

• CentralVenousAccess(SVCvsPAC)• ScvO2 andCVP• SvO2,CVP,PCWP,PVR,SVR,

Strokevolume

Inotropes• Intravenousmedicationsusedtoimprovecardiaccontractility

• Usefortheshortestdurationandatthelowestdosetomaintainperfusion

• AdverseRisks:– Increasedriskofatrialandventriculararrhythmias– SystemicHypotension– IncreasedMyocardialOxygenDemand

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Dobutamine• SyntheticcatecholaminethatstimulatesBeta1

receptors• Doesnotincreasebloodpressure;canstimulate

peripheralBeta2 receptorsthatcanleadtohypotension• Frequentlyassociatedwith:– Tachycardia– Arrhythmias:supraventricularandventricular– Increasedmyocardialoxygendemand

• Dosing:– 2to20mcg/kg/min

• Shorthalflife

Milrinone• Phosphodiesteraseinhibitor

– IncreasescyclicAMPlevelsthusincreasingintracellularcalciumlevels

– Netresultisincreasedinotropy• Vasodilationofbothpulmonaryandsystemiccirculatory

systems– Oftenrequirecombinationvasopressorsupport

• Nosignificantchronotropicaffects– Canleadtoarrhythmiasduetoincreaseinmyocardialoxygendemand

• Dose:– 0.125to0.75mcg/kg/min

• Longhalflife(2-6hours)– Renally cleared

Epinephrine• Catecholamine:nonspecificagonistofalladrenergic

receptorsBeta1,2,3, Alpha1,2 – dosedependent• Frequentlyassociatedwith:– Tachycardia– Hypertension– Arrhythmias:supraventricularandventricular– Increasedmyocardialoxygendemand

• Dosing:– 0.02to0.2mcg/kg/min

• Shorthalflife

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Vasopressors• Intravenousmedicationsusedtoimprovebloodpressure

• Usefortheshortestdurationandatthelowestdosetomaintainperfusion

• AdverseRisks:– Decreasedperipheraltissueperfusion– Decreasedmicrocirculation– Leadtotissuenecrosis

Norepinephrine• Catecholamine:potentvasoconstrictorAlpha1 –agonist

• Frequentlyassociatedwith:– Bradycardia– Hypertension– Arrhythmias:supraventricularandventricular– LimbIschemia

• Dosing:– 0.02to0.2mcg/kg/min(higherdosesusedinsepsis)

• Shorthalflife

Dopamine• Catecholamine:nonspecificagonistofalladrenergicreceptorsBeta1,2,3, Alpha1,2, Dopa –dosedependent

• Frequentlyassociatedwith:– Tachycardia– Arrhythmias:supraventricularandventricular– Increasedmyocardialoxygendemand

• Dosing:– 2 to20mcg/kg/min

• Shorthalflife

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FailureofMedicalManagement

• Persistenthypotension&hypo-perfusiondespiteuseof2ormoreinotropicand/orvasopressoragents

• Risinglacticacid• Evolvingorgandysfunction

ShortTermMCSDevices

1. IntraAorticBalloonPump(IABP)2. Impella3. TandemHeart4. ExtraCorporealMembraneOxygenation

(ECMO)

ShortTermMCS

• Optimaltiming/earlyinitiationofmechanicalsupport

• Optimallevelofsupporttorestoreadequateperfusionofendorgans

• Optimalpreventionandmanagementofpotentialdevicerelatedcomplicates

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IABP

• Heliumfilledballoon• Inflatesduringdiastole/DeflatesduringSystole• Volumeshifting~40mlperheartbeat(inc. SV)• CanincreaseCardiacOutput~0.5to1L

• DuringDiastole• IncreaseCoronaryPerfusion• Improvedreperfusionafterintervention

• DuringSystole• Hallmarkisafterloadreduction• ReductioninLVend-diastolicpressure• Reductioninpulmonarycapillarywedge

pressure• DecreaseinLVwallstressandmyocardial

oxygendemand

IABP• Percutaneouslyplacedviathefemoralarteryorleftaxillary

artery(7to8French)• Placedinthedescendingthoracicaorta

• Canbeplacedatthebedside,cath laborOR

• Quickinitiation

Complications• Bleeding• Hemolysis• Riskoflimbischemia• Vascularcompromise(dissection)

Management• Lowcomplexity• Trigger/Timingisautomatic(1:1,1:2,1:3)

• Anticoagulation• Heparindrip(PTTgoal40-50)

• Vascularchecks

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TandemHeart

• Acontinuousflowcentrifugalpump• Cansupplyupto4L/mincardiacoutput• Percutaneouslyplacedviathefemoralvessels:– 21Frinflowcannula:leftatriumviafemoralveinandthentrans-septalpuncture

– 15-17Froutflowinthefemoralartery• Placedinthecardiaccath lab

TandemHeart

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TandemHeart

• SuperiortotheIABPinimprovinghemodynamicendpoints:– Greaterincreaseincardiacoutput/cardiacindex– Greaterincreaseinmeanarterialpressure– Greaterdecreaseincardiacfillingpressures• ReducedPCWP,CVP,PAP

– Reducedcardiacworkloadandoxygendemand

TandemHeart• Complexityofinsertionlimitstheuse• Complications– Vascularcompromise– Malpositionofcannula

• Cancauseintracardiacshunt– Bleeding/Coagulopathies

• Insertionsite• GIB

– LimbIschemia– Infection

• SIRS/Sepsis– Stroke

Management

• Higherleveloftrainingrequired– Nursing,advancedpracticeproviders,physicians

• Anticoagulation– PTT50-60

• Vascularchecks• Deviceplacement– X-rayandEchocardiograms

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Impella

• ContinuousAxialFlowPump• Positionedacrosstheaorticvalveviaaccessfromthefemoralartery

• TypicallyplacedintheCathLaborOR– FluoroscopyandEchocardiogramguided– InterventionalCardiologyand/orSurgeon

Impella

• 3Impella Devices:1. Imeplla 2.5• 13Frcannulapercutaneouslyplaced• 12Frmirco-axialcatheterpump• Canprovideupto2.5LPMcardiacoutput

2. Impella CP• Percutaneouslyplaced• 14Frmirco-axialcatheterpump• Canprovideupto4.0LPMcardiacoutput

Impella

3. Impella 5.0• 22Frcannulaplacedbycutdownofthefemoral

artery• 21Frmicro-axialcatheterpump• Canprovideupto5.0LPMcardiacoutput• NeedsSurgicalrepairforremoval• Canalsobeplacedviaaxillaryartery

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Complications• Bleeding• Hemolysis• Riskoflimbischemia• AorticInsufficiency

• Vascularcompromise(dissection)

• Malposition

Management• Anticoagulation• Vascularchecks• Placement• Echocardiogramandx-ray

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Extracorporealmembraneoxygenation (ECMO)

• Atechniqueofprovidingcardiacand/orrespiratorysupporttopatientswhoseheartandlungsareunabletofunctionappropriately.

• Worksbyremovingbloodfromthebody,artificiallyremovingcarbondioxide,andre-oxygenatingredbloodcellspriortoreturningbloodbacktothebody.

ECMO:

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BasicPrinciplesofECMO• Supportforthefailingheartand/orlungs

– Mustmeetmetabolicdemands:• Cardiacoutput(VA)• AdequateoxygenationandCO2regulation

• Veno-arterial(VA)– Bypasses/reststheheart&lungs– Drainsbloodfromvenoussystem,returnsoxygenatedbloodtoarterialcirculation

• Veno-venous(VV)– Reststhelungs,relyingonnativecardiaccirculation– Drainsbloodfromvenoussystem,returnsoxygenatedbloodtovenoussystem(rightatrium)

• CentriMag– Magneticallylevitated,

centrifugalpump– 2-10LPM– Oxygenator&Bloodpump

areseparate

Circuit

• CardioHelp– Centrifugalpump– 2-10LPM– Bloodpump&oxygenatorare

1piece

Circuit

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• ECMO– Percutaneousplacementbyany

trainedproviderinanylocation:• Intensivist,Cardiologist,Surgeon,

EmergencyRoom

– ArterialAccess:15to19Fr– VenousAccess:21to27Fr– LimbPerfusioncatheter:5to7Fr– TypicalFlow4-6LPM– Providesbothcardiacand

pulmonarysupporttothepatient– CanincreaseAfterload(NoAI)

• Leadingtoincreasedmyocardialwallstress

– DecreasedLVPre-load– DecreasedPCWP

• Decreasedmyocardialoxygendemand

Management• BedsideNursevsPerfusion• Arterialbloodreturnedinretrogradedirection– 2Perfusioncircuits

• NativevsECMO• HarlequinSyndrome-->needtomonitoroxygenationfromrightradialartery

• Anticoagulation– HeparindripwithPTTgoal50-60– Hemorrhagevsemboliceventsvshemolysis

• VascularChecks

Complications

• Bleeding• Hemolysis• Limbischemia• Vascularcompromise(dissection)• Thromboembolicevents• AorticInsufficiency

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Summary• CardiogenicShockcontinuestocarryahighin-hospital

mortalityrate,40-50%despiteadvancesinearlyrevascularization

• Earlyidentificationandinitiationoftherapyisparamountinpreventingdevelopmentofmulti-systemorgandysfunction

• Hallmarktherapieswithinotropes/vasopressorandearlyrevascularizationhaveledtothereductionofmortality,butratesremainhigh

• Advancesinmechanicalcirculatorysupportofferinnovativewaystorestorecirculationandresttheheartbutfurtherresearchisneeded

Werdan,K.,EuropeanHeartJournal, 35:156-167.2014Shah,P.,Crit CareClin,30:391-412.2014

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