Percutaneous Mechanical Circulatory Support DevicesPercutaneous Mechanical

Circulatory Support DevicesFrom Guidelines to Practice

ModeratorDeepak L. Bhatt, MD, MPHProfessor of MedicineHarvard Medical SchoolExecutive Director of Interventional Cardiovascular ProgramsBrigham and Women's Hospital Heart and Vascular CenterBoston, Massachusetts

Atman P. Shah, MDAssociate Professor of MedicineClinical Director, Coronary Care UnitCo-Director, Adult Cardiac Catheterization LaboratoryUniversity of Chicago MedicineChicago, Illinois

Simon R. Redwood, MBBS, MDProfessor of Interventional CardiologySt Thomas HospitalKing’s College LondonLondon, United Kingdom

Panelists

• 57-year-old man presents with an anterior STEMI• PCI to LAD undertaken -- unable to reopen vessel despite prolonged

attempt• Persisting ST elevation at the end of case• BP 110/60 mm Hg• Transferred to CCU at 6 PM• Clinical deterioration by the following morning– Oliguric– Diaphoretic– Cool peripheries– Lactate 4– Persisting ST elevation– BP 120/80 mm Hg– ECHO -- poor EF -- 10%

• Transferred to cath lab for hemodynamic support in view of (incipient) cardiogenic shock

• 57-year-old man presents with an anterior STEMI• PCI to LAD undertaken -- unable to reopen vessel despite prolonged

attempt• Persisting ST elevation at the end of case• BP 110/60 mm Hg• Transferred to CCU at 6 PM• Clinical deterioration by the following morning– Oliguric– Diaphoretic– Cool peripheries– Lactate 4– Persisting ST elevation– BP 120/80 mm Hg– ECHO -- poor EF -- 10%

• Transferred to cath lab for hemodynamic support in view of (incipient) cardiogenic shock

Case Presentation

Presenting ECG

Courtesy of Simon R. Redwood, MBBS, MD.

Postprocedure ECG

Courtesy of Simon R. Redwood, MBBS, MD.

Stabilization After IABP ImplantationStabilization After IABP Implantation

Courtesy of Simon R. Redwood, MBBS, MD.

IABP 1:1; 2 min following deployment

IABP 1:1; 15 min following deployment

PAP; Pre-IABP - Mean 34

PAP; 2-min Post-IABP - Mean 27

Pulmonary Artery PressurePulmonary Artery Pressure

Courtesy of Simon R. Redwood, MBBS, MD.

OUTCOMEOUTCOME

• Pain and ST elevation settled over next 2 hours

• Lactate normalized

• IABP weaned 72 hours later

• Underwent successful CABG day 6

• Uncomplicated recovery, post-CABG EF 25%

CaseKey PointsCaseKey Points

• IABPs are most useful in patients who have persistent ischemia

• Routine use of IABPs does not provide an overall benefit

• Careful selection of eligible patients who have persistent ischemia can yield dramatic and life-saving results

Hemodynamic Effects of IABPHemodynamic Effects of IABP

• Increases diastolic blood pressure

• Decreases afterload

• Decreases myocardial oxygen consumption

• Increases coronary artery perfusion

• Modestly enhances cardiac output

• Modest ventricular unloading

• Increases mean arterial pressure and coronary blood flow

Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

Options for Mechanical Cardiopulmonary SupportOptions for Mechanical Cardiopulmonary Support• IABP

• Impella®

• TandemHeart™

• ECMO (Extracorporeal membrane oxygenation)

2013 ACCF/AHA Guideline for the Management of STEMI2013 ACCF/AHA Guideline for the Management of STEMI

• IIA Recommendation (Level of Evidence: B)

O’Gara PT, et al. Circulation 2013;127:e362-e425.

“The use of IABP can be useful for patients with cardiogenic shock after STEMI who do not quickly

stabilize with pharmacological therapy”

Cost-EffectivenessCost-Effectiveness

• Significant upfront cost of all the devices that many hospitals discourage

• Which device provides the best clinical utility?

• Prospect for a prolonged clinical benefit?

• What is an acceptable cost?

Possible Indications for Mechanical Circulatory Support DevicesPossible Indications for Mechanical Circulatory Support Devices

Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

Complications of AMISevere heart failure in the setting of nonischemic cardiomyopathyAcute cardiac allograft failurePosttransplant RV failurePatients slow to wean from cardiopulmonary bypass following heart surgeryRefractory arrhythmiasProphylactic use for high-risk PCIHigh-risk or complex ablation of ventricular tachycardiaHigh-risk percutaneous valve interventions

Balancing the Issue of CostSelecting the Right Device for the Right Patient

Balancing the Issue of CostSelecting the Right Device for the Right Patient• Many factors to consider, including– recent drop in blood pressure?– cardiac arrest patient?– cardiogenic shock?– high-risk PCI?– age of the patient– risk factors– EF– myocarditis? – structural heart complication?– do they need oxygenation?

Hemodynamic Support for the Cardiac Arrest SurvivorHemodynamic Support for the Cardiac Arrest Survivor• Start with IABP

– Lower cost

– Good effectiveness

– Quickest and most familiar way to obtain some degree of hemodynamic stabilization, especially in the setting of AMI with pump failure

• Step up to more supportive devices if patients do not stabilize

Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

Impella®Impella®

• Minimizes or eliminates pressor use

• Reduces myocardial oxygen demand

• Improves systemic perfusion, thereby avoiding systemic shock

Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

Vasopressors vs Support DevicesVasopressors vs Support Devices

• Consider any ongoing ischemia and the potential effect of increasing myocardial oxygen

• If the patient is not doing well on 1 IV vasopressor consider increasing the level of support to MCS

• Use of multiple pressors potentially increase the risk of arrhythmias

ECMOECMO

• Provides cardiopulmonary support for patients whose heart and lungs can no longer provide adequate physiologic support

– veno-veno for oxygenation only

– veno-arterial for oxygenation and circulatory support

• In the setting of interventional cardiology and PCI not used as a first-line agent

• Using ECMO with another device such as Impella or IABP may help in reducing afterload

Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

TandemHeart™TandemHeart™

• Pumps blood extracorporeally from the left atrium (LA) to the iliofemoral arterial system pump contribute flow to the aorta simultaneously (thereby working in parallel, or tandem)

• The redirection of blood from the LA reduces LV preload, LV workload, filling pressures, wall stress, and myocardial oxygen demand

• The increase in arterial blood pressure and cardiac output supports systemic perfusion

• Expertise with transseptal puncture is required

Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

MCS for High-Risk PCIMCS for High-Risk PCI

Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

Patient With Left Main, Last Remaining Conduit, or Severe Multivessel DiseaseNormal or mildly reduced left ventricular functionSevere left ventricular dysfunction (EF < 35%) or recent decompensated heart failure

Anticipated Noncomplex PCINoneIABP/Impella® as backup

Anticipated Technically Challenging or Prolonged PCIIABP/Impella as backupImpella® or TandemHeart™, choice dependent upon vascular anatomy, local expertise, and availability. ECMO for concomitant hypoxemia or RV failure.

A suggested schema for use of support devices for high-risk PCI based upon clinical and anatomic circumstances. The greater the likelihood of hemodynamic compromise or collapse the greater the potential benefit of MCS.

SummarySummary

• Routine use of hemodynamic support device is probably not necessary

• Individualize care to each patient

• Making early decision between device vs pressor and which device is important

• MCS devices have different characteristics– The IABP is very good at improving coronary flow in the presence

of persistent ischemia and has afterload reduction properties

– Impella® provides more support than the IABP at 3.5-5 L/min. It is used when patients are at more extreme risk or at the extreme end of the hemodynamics spectrum. Actively unloads the LV.

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