Mechanical Support for Acute Cardiogenic Shock Mark J. Russo, MD, MS Assistant Professor of Surgery Section of Cardiac and Thoracic Surgery University of Chicago

Disclosures No relevant disclosures

Severe Acute Cardiogenic Shock Associated w excessive mortality If untreated will lead to imminent death Etiology: Post-cardiotomy, AMI, Myocarditis, Acute on chronic cardiomyopathy, Malignant arrhythmia Goals: Must rapidly stabilize and “rest” heart Treatment: Mechanical support + OMM Endpoint: Recovery Definitive surgical therapy should not be offered in the acute setting

When and How to Initiate MCS

Simple Rules for Initiating MCS Pt continues to deteriorate despite increasing drugs Initiate before the patient absolutely needs it If you put an unsalvageable patient on MCS, they remain unsalvageable Its not the devices that are bad, it’s the patients who are sick

Hard Parameters for Initiating MCS Already on inotropes and IABP Increasing support level required Hemodynamics – must maintain CI >2.0 BP mean >60mmHg SBP> 85 mmg CVP <15 PCWP <20 End organ function : renal, hepatic, pulmonary, cerebral Balance Hemodynamics not attainable Increasing inotrope requirements especially vasoconstrictors

MCS Options Partial Circulatory Support Full Circulatory Support Full Cardiopulmonary Support

Partial Circulatory Support IABP Impella/Abiomed Subclavain-IABP

Impella Abiomed Micro rotary pump Advantages Less invasive 2.5 Cath lab, percutaneous insertion 5.0 (larger, more flow) Graft or cutdown Advantages Easy to insert Active de-compression of LV Less invasive Less support than rotary pumps

Impella Abiomed

Subclavian Intra-Aortic Balloon Intra-aortic balloon pumps (IABPs) are traditionally inserted through the femoral artery, limiting the patient’s mobility. Advantages of SC: PVD less of an issue, minimally invasive support, ambulatory Limitations: Time (40-1 hr), peri-stable, Connective tissue disease

Subclavian Intra-Aortic Balloon The graft is then tunneled into the pocket. The guidewire is though the skin and then into the graft and then through the subclavian artery into the aorta. Under fluoroscopic guidance, the balloon wire is positioned in the descending thoracic aorta. The balloon is inserted and screened into an appropriate position. The wound over the Gore-Tex graft is closed in layers.

Operative Approach

Ambulating with IABP

Outcomes (n=20) Mean duration of support : 21 days (range: 3 – 90) 19 patients (95%) were successfully bridged to transplant or LVAD. 2 patients (10%) required an emergent LVAD for worsening heart failure. All patients were extubated and ambulatory within 24 hours following the procedure No device-related complications while on support 1 device exchanged at bedside Introduction Methods Results Conclusions 15

Full Circulatory Support Extracorporeal VADs LVADs RVADs BIVADs Implantable VADs – are not for acutely decompensating patients Surgical trauma Bridge to ?

Management options – what to support? LVAD ECHO (function and MR) High filling pressures with hypotension and low CO PCWP >18 with mean BP <70mmHg and CI<1.8 RVAD ECHO (function and TR) CVP > 15mmHg with mPA < 1.5 x CVP Underfilled LV mPA > 2x CVP relative exclusion (may need LVAD or ECMO)

Centrimag Indications: Device: Short-term support (<15 days) Bridge-to-decision (recovery vs definitive therapy) Device: a single-use centrifugal pump, a motor, and a primary drive console. the motor magnetically levitates the impeller, achieving rotation with no friction or wear rotates at 1500-5500 rpm Flows: up to 9.9L/min

LVAD cannulation Surgical Outflow from device Inflow to device Aorta, femoral artery Inflow to device LA/PV LV

Centrimag Off Pump Sternotomy Left Thoractomy

RVAD cannulation Surgical Percutaneous Outflow from device PA - Do not push in too far RVOT across PV Inflow to device RA – careful positioning RV Percutaneous Via long cannula to PA Femoral vein, IJ, subclavian

Advantages of Centrimag Relatively inexpensive Reliable High level of support Allows for further esculation of care Implantable device RVAD ECMO

Case 65 year old male S/P traumatic right BKA after MVA Fully functional, employed as businessman Crescendo chest pain for 2 weeks, neglected Unrelenting angina for 24 hours before presenting to ER LHC performed

Coronary angiogram

Patient course Emergency IABP placed Transferred to tertiary care center Hemodynamic data BP 70/50 augmented PA 45/27 CVP 16 CI 1.2 Labs: Cr 2.5; TB 4.0; AST/ALT >1,000 Support: IABP, dopamine 20 mg/kg/min, dobutamine 20 mg/kg/min, ventilator with paO2 70 on FIO2 80%

Patient course Anuric Peripherally cold Obtunded ECHO: No AI Severe MR Moderate TR LVEF <10%, without thrombus

Hospital course Centri-Mag LVAD placed off pump. Reversed acidosis Recovered renal and hepatic function Pulmonary edema resolved Total CT output <300cc Anticoagulation started POD#1 Extubated POD#3 HeartMate II placed POD#5 to allow for rehabilitation

Full Cardiopulmonary Support Heart and pulmonary failure ECMO Standard (Thoratec Centri-mag/Maquet Quadrox) Portable (Maquet Cardiohelp)

Criteria With optimized ventilator settings pO2 < 65mmHg Sa02 < 90% PEEP > 10

Standard ECMO: Centrimag + Quadrox

In Situ Centrimag Quadrox

Advantages of Centrimag/Quadrox High level of support Reliable Relatively Inexpensive Peripheral/Percutaneous/Central Access Oxygenator can be cut-in to BIVAD/RVAD circuit at the bedside

Disadvantages of ECMO It does not decompress the heart unless LV vent placed Contraindicated in moderate to severe AI Oxygenator induced inflammatory response Need for anticoagulation ACT 150-200

CARDIOHELP – INSPIRING INNOVATIONS

Acute Respiratory Distress Syndrome (ARDS) Septic Shock Syndrome CRITICAL CARE MEDICINE POSSIBLE APPLICATIONS Acute Respiratory Distress Syndrome (ARDS) Septic Shock Syndrome Multiple Organ System Failure Pulmonary Embolism

CARDIOHELP All in one heart-lung support system 10 kg (22lbs) 14 x 10 x 17 inches Optional Sprinter Cart for in hospital mobility

Operating Room: Hybrid OR / Cath Lab: Critical Care Unit: General Surgery Neurosurgery Cardiac Surgery Vascular Surgery Interventional Cardiology Procedures Critical Care Unit: Patient Transport: MAQUET has been and will continue to be your partner in all areas you practice….. Cardiac Care Neonatal Intensive Care Options

TRANSFER OPTIONS Transfer pt and initiate at accepting center Transferring center initiates ECMO Convert to Cardiohelp Accepting initiates ECMO on site using Cardiohelp In cardiovascular disease, we have a just say “YES” policy

Case 54yo M p/w CP to outside ED Troponin 20 Taken to cath lab Found to have RCA occlusion Intervention unsuccessful Worsening stability c high dose pressors Intubated/IABP placed Transferred to UofC

Case Airlifted to UofC Directly to the OR Peripherally cool, MAPs 55, anuric, SaO2 85% Lactate: 7, pH 7.21, pO2 57 ECHO: severe RV failure, LVEF=35%

Case Peripheral cannulation via femoral cutdown RFA – arterial inflow RFV – venous drainage Antegrade to RFA via 12Fr cannula

Case OR Flow: 6.0L, FiO2=100% MAPs 70s, SaO2=100% HD#1 Weaning pressors CVVHD pH normalized, PaO2=300s HD#4 Off pressors and inotropy

Case HD#6 Weaned from ECMO after 2 day wean Wean flows IABP, inotropy Extubated HD#12 Off inotropy HD#19 Discharged to rehab

Support initiated – then what? Maintenance: Anticoagulation Initial – ECMO ACT 150 – 180, VAD none After bleeding stops – 150 – 180 sec Minimize inotropic support Evaluate cerebral and other end organ function IABP for some pulsatility End goals: Recovery and wean Bridge to longer term solution Definitive surgical treatment is not appropriate in acute setting

Weaning / recovery Native ejections with decreasing support Allow time to re-equilibrate Continuous SG useful for LVAD (even for RVAD as it give MVO2 saturation) ECHO Minimize anesthesia Bad sign if escalating inotropes or requiring IABP

Outcomes Difficult to characterize given heterogeneity of patients Recovery depends on ability to repair myocardium Bridge to device depends on: Earlier initiation of mechanical therapy Single vs bi-VAD support Liver function marker for survival Respiratory status Neuro Reports vary from 30 – 80% success rates

Summary Paradigm shift Initiate earlier Better less inflammatory technology Easier to initiate Better Outcomes

Take Home Points MCS should be initiated early Temporary support, not implantable device Definitive therapy should only be offered after patient demonstrates measurable recovery