Clinic of Cardiovascular and Thorax Surgery Bad Rothenfelde, Germany 5rd International Prof. Dr. Alireza Yalda Foundation in Medical Sciences Mechanical support of the heart in cardiogenic shock 6-10 October, 2014, Tehran, Iran Abbas Ferdosi, M.D. Clinic of Cardiovascular and Thorax Surgery Bad Rothenfelde, Germany

Pathophysiology of cardiogenic shock

Mortality has been decreased since 2003 < 75 J: 62% >>> 50% ≥ 75 J: 35% >>> 30% Mortality female> male Germany / year 280,000 myocardial infarctions 40% STEMI 112000 10% followed by CS 11000

Results Schuechtermann Clinic Bypass surgery in acute myocardial infarction (<24h) 1/2004 - 09/2006 n = 321 (30-day mortality was 10%) Myocardial infarction Without shock In shock n 211 110 30 days mortality 1,4% 27% Age (years) 67,3 (38-94) 66,5 (33-85) EF < 30% 14,2% 56,3%

Mechanical Option Intra Aortic Balloon Pump (IABP) Extra Corporeal Membrane Oxygenation (ECMO) Impella

IABP An investigation was undertaken to determine whether the blood supply through narrowed coronary arteries could be improved by delaying the arterial pressure wave so that it arrives in the coronary arteries during diastole. In 1967 it was clinical introduction. Currently 100.000 implantation per year.

Intra-Aortic Balloon Pump (IABP) functional principle Intra-Aortic Balloon-counterpulsation

IABP functional principle

IABP functional principle

IABP functional principle Diastole Balloon inflates Increased blood flow to coronaries Systolie Balloon deflates Afterload is reduced Increased forward blood flow

Effects of IABP Therapy Coronary perfusion Stroke Volume Ventricular Emptying Cardiac output LV Workload Myocardial oxygen Demand

IABP- Indication Cardiogenic shock Intractable angina pectoris Low cardiac output after CABG Support for diagnostic, percutaneous revascularisations and interventional procedures Others…

Contraindication Severe aortic regurgitation Aortic dissection Aneurysm of the abdominal or thoracica aorta Severe calcific aorto- iliac disease or peripheral vascular

Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock Holger Thiele, M.D., Uwe Zeymer, M.D., Franz-Josef Neumann, M.D., Miroslaw Ferenc, M.D., Hans-Georg Olbrich, M.D October 10, 2012 CONCLUSIONS The use of intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in nupatients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned. (Funded by the German Research Foundation and others; IABP-SHOCK II ClinicalTrials.gov mber, NCT00491036.)

Extra Corporeal Membrane Oxygenation (ECMO) A form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to an oxygenator where blood becomes enriched with oxygen and has carbon dioxide removed.

ECMO The blood is than returned to the patient via a central vein or an artery.

ECMO cannulation

ECMO cannulation

ECMO function Reduction of preload and afterload Oxygenation of the blood

ECMO indication Cardiogenic shock Post cardiotomy Bridge to HTX/VAD Graft failure Myocarditis ECMO-CPR

ECMO Contraindications Severe calcific aorto- iliac disease or peripheral vascular Multi-Organ Failure End-stage Disease

ECMO complication Peripheral arterial disease Compartment syndrome

Impella The smallest heart pump in the world 9 Fr catheter, 12 Fr / 14Fr microaxial Produces 2.5 / -4 L / min forward flow Increases: coronary flow the systemic flow cardiac output which is in direct correlation to mortality

Impella Discharges directly to the Ventricle: The pump pumps the blood from the LV Resulting in a reduction of the wall voltage Reduction of O2 demand in the myocardium While at the same time increases the O2 supply Regardless of the heart rhythm and catecholamines

Physiological effect of Impella support 2525 Physiological effect of Impella support HCS-PP00022-004 rA EU

Impella® Controller (AIC) Impella Controller (AIC) for monitoring and control of the Impella pump and the purge system.

Promotion of blood The rotating drive sucks blood through the cannula Impella controller (AIC) controls the rotation speed of the drive The rotational speed is proportional to the flow Faster rotation = Higher flow Motor Impeller cannula HCS-PP00022-006 rA EU

Impella® Circulatory Support Platforms Impella CP Impella 5.0 Impella LD Flow Rate (L/min) 2.5 3.7 – 4.0 5.0 Circulatory Support Partial Partial - High High-flow Catheter Size 9 Fr Pump Size 12 Fr 14 Fr 21 Fr Insertion Method Percutaneous Arterial Cut down Surgical Insertion

Impella

Impella increases perfusion Myocardial Protection … O2 Supply Increased Myocardial Blood Flow, Aqel et al. (2009) Blood Flow (Coronary Arteries & Microvasculature) AOP MR Improvement in Myocardial Perfusion with Impella Support (Tc-99 MIBI Imaging) a Impella OFF Impella ON Aortic Pressure (AOP) Under-perfused area Impella increases perfusion Microvascular Resistance (MR)

Myocardial Protection … O2 Supply Unloading Reduces Infarct Size…Impella vs IABP Meyns et al., JACC (2003)

Circulation. 2012 Oct 2;126(14):1717-27. 10. 1161/CIRCULATIONAHA. 112 Circulation. 2012 Oct 2;126(14):1717-27. 10.1161/CIRCULATIONAHA.112.098194. Epub 2012 Aug 30. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study. O'Neill WW1, Kleiman NS, Moses J, Henriques JP, Dixon S, Massaro J, Palacios I, Maini B, Mulukutla S, Dzavík V, Popma J, Douglas PS, Ohman M. CONCLUSIONS: The 30-day incidence of major adverse events was not different for patients with IABP or Impella 2.5 hemodynamic support. However, trends for improved outcomes were observed for Impella 2.5-supported patients at 90 days.

Conclusion Early mechanical support of the heart reduces mortality in cardiogenic shock.

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