ST-Elevation Myocardial Infarction & Cardiogenic Shock - What Should We Do? Advanced Angioplasty 2008 Dan Blackman Leeds General Infirmary

Conflicts of interest Advisory Boards –Cordis –Boston Scientific –Medtronic –Nycomed –Lilly –St Jude Travel/Sponsorship –Cordis –Boston Scientific –Medtronic –Abbott –St Jude

Causes of Cardiogenic Shock Predominant LV Failure 74.5% Acute Severe MR 8.3% VSD 4.6% Isolated RV Shock 3.4% Tamponade/rupture 1.7% Other 7.5% Shock Registry JACC :1063

Survival from mechanical causes Shock Registry JACC 2000;36:1104 & 36: 1110 GUSTO 1 Circulation 2000;101:27 Holzer R CCI 2004;61:196

Emergency revascularisation - SHOCK Trial 85% of survivors NYHA Class I/II at 12 months Hochman JAMA 2000;285:190 p=0.11 p=0.03

Emergency revascularisation in the Elderly - SHOCK Trial >75 years ERV vs IMS baseline characteristics –LVEF 28% vs 36% p=0.051 –Anterior MI 63% vs 41% p=0.18 –Female 54% vs 31% p=0.11 p=0.01

Elderly - SHOCK & other registry data n=44n=233n=61 n=74

Single vessel or Multivessel PCI? - SHOCK Trial 81% of PCI patients multivessel disease 85% PCI IRA only; 23% complete revascularisation p<0.01 Shock Trial Shock Registry p=NS

“The panel believes that all accessible vessels should be treated in patients with cardiogenic shock” “Current Recommendations:- 1-2 vessel disease: PCI IRA 3VD: PCI IRA + staged complete revascularisation Early MV PCI may be warranted if shock persists despite IRA PCI”

Is there a role for CABG – SHOCK Data p=NS SHOCK Trial CABG vs PCI baseline characteristics –LMS Disease 41% vs 13% p=0.051 –3VD 80% vs 60% p=0.18 –Diabetes 49% vs 27% p=0.11 n=47n=81n=276n=109

Intra-aortic balloon pump counterpulsation

IABP in Cardiogenic Shock Primary PCI Retrospective analysis of 23,180 patients from NRMI database 7268 treated by IABP

Timing of IABP in Cardiogenic Shock Primary PCI Single centre registry Primary PCI for shock Brodie AJC 1999;84:18

Inotropes and Vasopressors No meaningful data! ACC/AHA Guidelines SBP <70:- Norepinephrine (  g/min) Switch to Dopamine (5-15  g/kg/min) once SBP ≥80 SBP Dopamine (5-15  g/kg/min) Add dobutamine (2-20  g/kg/min) once SBP ≥90

Percutaneous left ventricular assist devices Even with revascularisation and IABP support mortality from cardiogenic shock post STEMI remains ≥50% Recovery of myocardial performance following successful revascularisation may take several days. During this time many patients succumb to low cardiac output If effective, active cardiac support could be provided while awaiting the beneficial effects of revascularisation, survival rates may be enhanced

Tandem Heart pLVAD Left atrial-to-femoral arterial LVAD Low speed centrifugal continuous flow pump 21F venous transeptal cannula 17F arterial cannula Maximum flow 4L/minute Cost: 7.5K

Tandem Heart Outcome Data Improved haemodynamic parameters Increase in bleeding, limb ischaemia, and sepsis Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1 p=NS

Impella Axial flow pump Much simpler to use Increases cardiac output & unloads LV LP 2.5 –12 F percutaneous approach; Maximum 2.5 L flow LP 5.0 –21 F surgical cutdown; Maximum 5L flow Cost: 3-5K Pressure Lumen Motor Blood outlet Blood Inlet

Impella outcome data 1 RCT of Impella 2.5 in AMI Cardiogenic Shock ISAR-SHOCK –26 patient RCT Impella vs IABP –  Cardiac Index,  MAP (by 10mmHg) vs IABP –Complications ≤ IABP –No difference in mortality

What we should do about STEMI Cardiogenic Shock Emergency angiography and revascularisation: Primary PCI preferably –All patients <75 years –Selected patients ≥75 years On-table echo to rule out mechanical defects Stabilise the patient in the lab before revascularisation –IABP –Pressors if required (Norepinephrine/dopamine) –Anaesthetic support Consider calling the surgeon for true surgical disease PCI culprit artery. Other vessels if shock persists Use abciximab for PCI Consider percutaneous LVAD if shock persists with IABP + multi-vessel revascularisation