shock is the new stemi future directions in cardiogenic shock · •acute stemi (anterior st...
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Navin K. Kapur, MD, FACC, FSCAI, FAHA
Associate Professor, Department of Medicine
Interventional Cardiology & Advanced Heart Failure Programs
Executive Director, The Cardiovascular Center for Research & Innovation
Shock is the New STEMIFuture Directions in Cardiogenic Shock
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Relevant Disclosures
Research Funding & Speaker/Consulting Honoraria:
Abiomed, Abbott, Boston Scientific, Maquet, Medtronic, MD Start, Cardiac Assist
Herbert J. Levine
Foundation
Tufts Medical Center
RO1HL139785, RO1H133215
Charlton Award
Tufts Medical Center
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Triage and Transfer for STEMI
The Hub and Spoke Model
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Triage and Transfer for Cardiogenic Shock
The Hub and Spoke Model
AHA Consensus Statement 2017
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ECG = STEMI PAC = SHOCK
Rapid, Available, and High Yield Diagnostic Tools
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From Drugs to Devices in STEMI and Shock
Drug Device
Drug Device
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Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision making
Kapur et al. Curr Cardiol. 2016
Change 1: Pheno-profiling Cardiogenic Shock
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1010 Cases
CP + RP
IABP only
Impella 5.0
Impella 5.0 + RP
Impella CP
Impella RP
No AMCS
Other
VA ECMO
VA ECMO + Impella CP
176, 22%
178, 22%
145, 18%
16, 2%
24, 3%
5, 1%
2, <1%
162, 20%
83, 10%
27, 3%
Impella VA-ECMO 0
20
40
60
80
100
Pulmonary Artery Catheter Pre-AMCSM
ort
ality
(%
)
No
Yes
p<0.001
A B
C D
<9 9-12 13-17 ≥180
20
40
60
Right Atrial Pressure (mmHg)
Mo
rtality
(%
)
*
*
†
†‡
142 120 136 178
*, p<0.05: Compared to RAP <9 mmHg†, p<0.05: Compared to RAP 9-12 mmHg‡, p<0.05: Compared to RAP 13-17 mmHg
<9 9-12 13-17 ≥180
20
40
60
Right Atrial Pressure (mmHg)
Mo
rtality
(%
)
*
*
†
†‡
142 120 136 178
*, p<0.05: Compared to RAP <9 mmHg†, p<0.05: Compared to RAP 9-12 mmHg‡, p<0.05: Compared to RAP 13-17 mmHg
NonCongested
LV RV BIV0
20
40
60
80
100
Mo
rtality
(%
)
103 189 34 246
* †* †
*, p<0.05: Compared to Non-congested†, p<0.05: Compared to LV-dominant
Let the Hemodynamics Guide Your Decision Making
Morine & Kapur et al. Shock Working Group
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Courtesy of D. Burkhoff Kapur Lab
Change 2: LV Unloading as a Therapy not Simply an
Adjunctive Intervention for Support
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Lija Swain : Kapur Lab 2018
Ingenuity Pathway Analysis
Mitochondrial Dysfunction
Oxidative Phosphorylation
Sirtuin Signaling Pathway
TCA Cell Cycle
Fatty Acid b-oxidation
Beta-adrenergic signaling
Change 2: LV Unloading as a Therapy not Simply an
Adjunctive Intervention for Support
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An Integrated View of AMI and Shock Biology
C
Kapur Lab
Ventricular Load Impacts Myocardial Recovery
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O’Neill W. JIC 2013
Change 2: LV Unloading as a Therapy not Simply an
Adjunctive Intervention for Support
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Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision making
Biventricular Congestion in Shock is
Common and Deadly
NonCongested
LV RV BIV0
20
40
60
80
100
Mo
rtality
(%
)
13/98 32/180 14/32 99/235
* †* †
Cardiogenic Shock Working Group
0 10 20 30 400
20
40
60
80
RAP (mmHg)
PC
WP
(m
mH
g)
Total Congestive Profiles Scatterplot
Non-Survivor
Survivor
14
18
Change 3: Unloading and Decongestion
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<9 9-12 13-17 ≥180
10
20
30
40
50
Right Atrial Pressure (mmHg)
Mo
rtality
(%
)
*
*
†
†‡
134 113 130 168
<9 9-12 13-17 ≥180.0
0.5
1.0
1.5
2.0
2.5
Right Atrial Pressure (mmHg)S
eru
m C
reati
nin
e (
mg
/dl)
p<0.001
Right Atrial Pressure is a common denominator for poor outcomes
Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision makingVenous Congestion Drives Mortality and Morbidity
Cardiogenic Shock Working Group
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Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision makingRecognizing the Cardio-Renal Axis in Shock
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Patel and Bezerra et al ASAIO 2018
Change 4: Optimizing ECMO Venting Strategies
Superior Outcomes with EcPella vs ECMO
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Antegrade Perfusion6Fr Braided Sheath
Impella CP 14Fr Sheath
PA Catheter 8Fr Cordis
17Fr Arterial Cannula25Fr MS Venous Cannula
Antegrade Perfusion6Fr Braided Sheath
High Pressure 3-Way + 2 Male-to-Male
Connectors
Change 5: Increasing Focus on Vascular
Outcomes (Deployment and Removal)
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2 x 035 wires through7/14Fr telescoping sheath
RemovingCP & Repo Sheath
Side-arm stylet removedCath Lab – sterile prepAntibiotics on board
Sheaths out. 7Fr buddy dilatorPerclose Number 1 at 10:00 Dry Bed with Perclose 1 Hemostasis with 2 Perclose
devices and 10 minute hold
Change 5: Increasing Focus on Vascular
Outcomes (Deployment and Removal)
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From Door to Support to Door to Unload
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Percutaneous Left Atrial Decompression Reduces LV
Wall Stress and Reduces Infarct Size
Kapur NK et al Circulation 2013
Introduced a 30 minute delay to reperfusion
after LV Unloading
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Kapur NK et al JACC HF 2015
Primary Unloading : Impella Micro-Axial Pump
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Reperfusion Unloading Reperfusion Unloading0
5
10
15
20
% S
car
by L
GE
or
An
ato
mic
Path
olo
gy
LGE by CMR Anatomic Pathology
p = 0.03 p = 0.02
Primary Unloading Reduces LV Scar and Preserves Cardiac
Output 30 days after Acute MI
Esposito, Zhang, Qiao and Kapur et al JACC 2018
Heart Attack (no pump)
Heart Attack (+ Pump)
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Reperfusion
Alone15 min 30 min Unloading After
ReperfusionUnloading Before
Reperfusion
Unloading First & Delaying Reperfusion
Maximally Reduces Infarct Size (Preclinical)
*
JACC 2018
DTU-Pilot
DTU-Pivotal
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Door To Unload: STEMI Safety & Feasibility Trial
Informed Consent
Enrollment and Randomization
Explant Impella CP after a minimum of 3 hours support
INCLUSION CRITERIA• Age 21-80 years• First Myocardial Infarction• Acute STEMI (anterior ST elevation ≥2 mm in ≥2 contiguous or ≥4 mm ST-sum)• Within 1 to 6 hours of symptom onset
Anterior STEMI Referred for Primary PCI
Impella CP Insertion + Activation
LV Unloading, Then Immediate PCI Reperfusion
(U-IR Group)
LV Unloading for 30 minutes,Then Delayed Reperfusion
(U-DR Group)
ENROLLMENT COMPLETED
May 2018
Late Breaking Presentation at
AHA 2018 – Chicago – Nov 2018