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

2. Disclosures
No relevant disclosures

3. 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

4. When and How to Initiate MCS

5. 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

6. 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

7. MCS Options Partial Circulatory Support Full Circulatory Support
Full Cardiopulmonary Support

8. Partial Circulatory Support
IABP
Impella/Abiomed
Subclavain-IABP

9. 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

10. Impella Abiomed

11. 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

12. 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.

13. Operative Approach

14. Ambulating with IABP

15. 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

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

17. 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)

18. 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 rpm
Flows: up to 9.9L/min

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

20. Centrimag
Off Pump
Sternotomy
Left Thoractomy

21. 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

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

23. 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

24. Coronary angiogram

25. 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%

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

27. 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

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

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

30. Standard ECMO: Centrimag + Quadrox

31. In Situ
Centrimag Quadrox

32. 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

33. 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

34. CARDIOHELP – INSPIRING INNOVATIONS

35. 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

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

37. 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

38. 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

39. 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

40. 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%

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

42. 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

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

44. 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

45. 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

46. 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

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

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