Athanassios Antonopoulos MD, PhD, FESC, FACCU.O. Cardiologia Faenza (RA), Emilia Romagna, IT

No conflict of interest

Goldberg RJ et al, Circulation 2009

Goldberg RJ et al, Circulation 2009

mortality

SHOCK Trial: Age < 75

0

20

40

60

80

30 Day Mortality

41.4%

56.8%%

P < .01

0

20

40

60

80

6 Month Mortality

44.9%

65.0%

Hochman et al, NEJM 1999; 341:625.

Immediate Revascularization StrategyMedical Stabilization as an Initial Strategy

P < 0.002

SHOCK Trial: Age > 75

0

20

40

60

80

30 Day Mortality

75.0%

53.1%%

P < .01

0

20

40

60

80

6 Month Mortality

79.2%

56.3%

Hochman et al, NEJM 1999; 341:625.

Immediate Revascularization StrategyMedical Stabilization as an Initial Strategy

P < 0.003

Long-term follow-up of the SHOCK trial cohort. Early revascularization (ERV) is associated with sustained benefit.

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

Copyright © American Heart Association, Inc. All rights reserved.

Functional status in the SHOCK trial. The majority of patients who survived 2 weeks after discharge had good functional status (and quality of life) at that time point.

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

Copyright © American Heart Association, Inc. All rights reserved.

Causes

Cardiogenic shock is a spectrum

Range of LVEF in studies of heart failure and in the SHOCK trial.

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

Figure 3. Iatrogenic shock.

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

SHOCK Trial

Tsuneyoshi I Crit Care Med 2001; 29:487

http://www.tctmd.com/expert-presentations/table-2.html?product_id=8769&title=Cardiogenic%20Shock%20&%20Hemodynamic%20Support&sort_key=27&large_image_p=1

Levosimedan very early in cardiogenic shock, effects lasting for at least 72 h,no pro-arrhythmic effects

IMPORTANT

Algorithm for revascularization strategy in cardiogenic shock, from ACC/AHA guidelines. Whether shock onset occurs early or late after MI, rapid IABP placement and

angiography are recommended.

Harmony R. Reynolds, and Judith S. Hochman Circulation. 2008;117:686-697

Sheidt, NEJM 1973; Mueller, Circ 1972

One complete cardiac cycle and the corresponding waveform of the IABP during inflation and deflation.

Murli Krishna, and Kai Zacharowski Contin Educ Anaesth Crit Care Pain 2009;9:24-28

© The Board of Management and Trustees of the British Journal of [2009]. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Remember the IABP curve …

Endocardial Viability Ratio: DPTI / TTI

DPTI= the net area between aortic pressure and left ventricular pressure during diastole. TTI= the area under the LV systolic curve is well correlated w myocardial oxygen demand for total left ventricular work

DPTI = oxygen supply

TTI = oxygen demand

Prondzinsky et al. SHOCK 2012;37:378-384

Gaps !

patients for surgery

Perera, et al ACC 2012

IABP in high risk pts for non-cardiac surgery

patients with coronary artery disease (CAD) for whom bypass grafting is not an option due to: (1) inoperable CAD; (2) a severe coexisting disease process (such as a malignancy); or (3) the emergent nature of the noncardiac procedure.

The decision analysis suggests that patients whose preoperative assessment places them at very high risk for postoperative complications (Goldman class IV or Detsky class III undergoing major surgery) may benefit the most from prophylactic placement of an IABP prior to noncardiac surgery.

Thank you….