Assist Devices for the Treatment of Cardiogenic Shock

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Presentation transcript:

Assist Devices for the Treatment of Cardiogenic Shock Ezequiel J Molina, MD Attending Cardiac Surgeon Advanced Heart Failure and Transplant Program MedStar Heart and Vascular Institute – Washington Hospital Center Washington, DC I have no relevant financial relationships

Background Mortality rate of refractory cardiogenic shock is high Early initiation of MCS may improve outcomes Avoid progression of MSOF and optimize organ function Potential outcomes: Heart recovery Heart transplantation Temporary or durable LVAD Withdrawal of care and death

Ideal Support Device Easy and rapid implementation Provide robust hemodynamic support Biventricular support when needed Allow pulmonary support Cost effective Multidisciplinary team approach

Device Selection Patient status and location Etiology of cardiogenic shock Technology available at your institution Devices: VA ECMO CentriMag LVAD Durable LVAD

VA ECMO

VA ECMO Abrams et al, J Am Coll Cardiol, 2014

ELSO Survival Data

ECMO Outcomes AMI Negi et al, J Invasive Cardiol, 2016

ECMO Outcomes AMI Negi et al, J Invasive Cardiol, 2016

ECMO Advantages Allows for minimally invasive Rapid bedside application Biventricular support Pulmonary support Low initial cost Transport capabilities

ECMO Advantages

ECMO Disadvantages Labor intensive High cost with prolonged support Requires anticoagulation LV distension / thrombosis Historically high complication rates Limited duration of support

LV Distension Inotropes Minimize vasoconstriction Central cannulation LV vent insertion LVAD conversion Impella / Tandem Heart

CentriMag LVAD

CentriMag LVAD Magnetically levitated centrifugal blood pump Low shear stress of blood components LVAD, RVAD or BiVAD Allows ECMO (oxygenator) Flows up to 10 L/min Optimal LV decompression Bridge to recovery, transplant or long term device

Disadvantages of CentriMag LVAD More expensive than ECMO Requires sternotomy Thromboembolic complications Anticoagulation / Bleeding May select patients with no exit strategy

CentriMag LVAD Takayama et al, J Heart Lung Transplant, 2013

Durable LVADs

INTERMACS Profiles

Durable LVADs Kirklin et al, J Heart Lung Transplant, 2015

LVAD Survival Kirklin et al, J Heart Lung Transplant, 2015

LVAD Survival Kirklin et al, J Heart Lung Transplant, 2015

Conclusions Early and rapid recognition of cardiogenic shock Robust hemodynamic support may improve outcomes ECMO is our first line of therapy for cardiopulmonary support… before MSOF CentriMag LVADs as bridge to recovery, transplantation or durable LVADs Durable LVADs can be successful in selected INTERMACS 1 patients Teamwork and communication at each stage is critical Management guidelines are needed but difficult to develop

Q&A

Tandem Heart

Tandem Heart Cheng et al, European Heart Journal, 2009