abbas ferdosi m.d.oct. 2014 5 rd international prof. dr. alireza yalda foundation in medical...

Abbas Ferdosi M.D. Oct. 2014

5rd International Prof. Dr. Alireza Yalda Foundation in Medical Sciences

Mechanical support of the heart in cardiogenic shock

6-10 October, 2014, Tehran, Iran

Abbas Ferdosi, M.D.

Clinic of Cardiovascular and Thorax Surgery

Bad Rothenfelde, Germany


Pathophysiology of cardiogenic shock


- Mortality has been decreased since 2003

< 75 J: 62% >>> 50% ≥ 75 J: 35% >>> 30% - Mortality female> male

Germany / year - 280,000 myocardial infarctions - 40% STEMI

112000 - 10% followed by CS

11000


Myocardial infarction Without shock In shock

n 211 110

30 days mortality

1,4% 27%

Age (years) 67,3 (38-94) 66,5 (33-85)

EF < 30% 14,2% 56,3%

ResultsSchuechtermann Clinic Bypass surgery in acute myocardial infarction (<24h) 1/2004 - 09/2006 n = 321 (30-day mortality was 10%)


• Intra Aortic Balloon Pump (IABP)

• Extra Corporeal Membrane Oxygenation (ECMO)

• Impella

Mechanical Option


An investigation was undertaken to determine whether the blood supply through narrowed coronary arteries could be improved by delaying the arterial pressure wave so that it arrives in the coronary arteries during diastole.In 1967 it was clinical introduction.Currently 100.000 implantation per year.

IABP


Intra-Aortic Balloon Pump (IABP) functional principle

Intra-Aortic Balloon-counterpulsation


IABP functional principle


IABP functional principle

Diastole

- Balloon inflates- Increased blood flow to coronaries

Systolie

- Balloon deflates- Afterload is reduced- Increased forward blood flow


Effects of IABP Therapy

Coronary perfusion

Stroke Volume

Ventricular Emptying

Cardiac output

LV Workload

Myocardial oxygen Demand


IABP- Indication

- Cardiogenic shock

- Intractable angina pectoris

- Low cardiac output after CABG

- Support for diagnostic, percutaneous revascularisations and

interventional procedures

- Others…


Contraindication

- Severe aortic regurgitation

- Aortic dissection

- Aneurysm of the abdominal or thoracica aorta

- Severe calcific aorto- iliac disease or peripheral vascular


CONCLUSIONSThe use of intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in nupatients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned. (Funded by the German Research Foundation and others; IABP-SHOCK II ClinicalTrials.gov mber, NCT00491036.)

Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock

Holger Thiele, M.D., Uwe Zeymer, M.D., Franz-Josef Neumann, M.D., Miroslaw Ferenc, M.D.,Hans-Georg Olbrich, M.D October 10, 2012


Extra Corporeal Membrane Oxygenation(ECMO)

• A form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to an oxygenator where blood becomes enriched with oxygen and has carbon dioxide removed.


ECMO• The blood is than returned to the patient via a central vein

or an artery.


ECMO cannulation


ECMO function

• Reduction of preload and afterload

• Oxygenation of the blood


ECMO indication

- Cardiogenic shock

- Post cardiotomy

- Bridge to HTX/VAD

- Graft failure

- Myocarditis

- ECMO-CPR


ECMO Contraindications

- Severe calcific aorto- iliac disease or peripheral vascular

- Multi-Organ Failure

- End-stage Disease


ECMO complication

- Peripheral arterial disease

- Compartment syndrome


- The smallest heart pump in the world

- 9 Fr catheter, 12 Fr / 14Fr microaxial

- Produces 2.5 / -4 L / min forward flow

Increases:

- coronary flow

- the systemic flow

- cardiac output

which is in direct correlation to mortality

Impella


Discharges directly to the Ventricle:

- The pump pumps the blood from the LV

- Resulting in a reduction of the wall voltage

- Reduction of O2 demand in the myocardium

- While at the same time increases the O2 supply

Regardless of the heart rhythm

and catecholamines

Impella


Physiological effect of Impella support 25

HCS-PP00022-004 rA EU


Impella® Controller (AIC)

Impella Controller (AIC) for monitoring and control of the Impella pump and the purge system.


Promotion of blood

Motor Impeller cannula

- The rotating drive sucks blood through the cannula

- Impella controller (AIC) controls the rotation speed of the drive

- The rotational speed is proportional to the flow

- Faster rotation = Higher flow

HCS-PP00022-006 rA EU


Impella® Circulatory Support Platforms

Impella 2.5 Impella CP Impella 5.0 Impella LDFlow Rate (L/min) 2.5 3.7 – 4.0 5.0 5.0

Circulatory Support Partial Partial - High High-flow High-flow

Catheter Size 9 Fr 9 Fr 9 Fr 9 Fr

Pump Size 12 Fr 14 Fr 21 Fr 21 Fr

Insertion Method Percutaneous Percutaneous Arterial Cut down Surgical Insertion

Impella


Impella


Impella ON

Impella increases perfusion

Impella OFF

Under-perfused area

Improvement in Myocardial Perfusion with Impella Support (Tc-99 MIBI Imaging)

Increased Myocardial Blood Flow, Aqel et al. (2009)

MicrovascularResistance (MR)

Aortic Pressure

(AOP)

Myocardial Protection … O2 Supply

Blood Flow(Coronary Arteries & Microvasculature)

AOP

MRa


Unloading Reduces Infarct Size…Impella vs IABP Meyns et al., JACC (2003)

Myocardial Protection … O2 Supply


Circulation. 2012 Oct 2;126(14):1717-27. 10.1161/CIRCULATIONAHA.112.098194. Epub 2012 Aug 30.A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study.

O'Neill WW1, Kleiman NS, Moses J, Henriques JP, Dixon S, Massaro J, Palacios I, Maini B, Mulukutla S, Dzavík V, Popma J, Douglas PS, Ohman M.

CONCLUSIONS:The 30-day incidence of major adverse events was not different for patients with IABP or Impella 2.5 hemodynamic support. However, trends for improved outcomes were observed for Impella 2.5-supported patients at 90 days.


Conclusion

Early mechanical support of the heart reduces

mortality in cardiogenic shock.


Tank you for

your attention

abbas ferdosi m.d.oct. 2014 5 rd international prof. dr. alireza yalda foundation in medical...

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iran abbas ferdosi

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