1. 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

2. Pathophysiology of cardiogenic shock

3. 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

4. Results Schuechtermann Clinic
Bypass surgery in acute myocardial infarction (<24h)
1/ /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%

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

6. 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 implantation per year.

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

8. IABP functional principle

9. IABP functional principle

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

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

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

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

14. 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, NCT )

15. 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.

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

17. ECMO cannulation

18. ECMO cannulation

19. ECMO function Reduction of preload and afterload
Oxygenation of the blood

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

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

22. ECMO complication
Peripheral arterial disease
Compartment syndrome

23. 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

24. 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

25. Physiological effect of Impella support
2525
Physiological effect of Impella support
HCS-PP rA EU

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

27. 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-PP rA EU

28. 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

29. Impella

30. 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)

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

32. Circulation. 2012 Oct 2;126(14):1717-27. 10. 1161/CIRCULATIONAHA. 112
Circulation. 2012 Oct 2;126(14): /CIRCULATIONAHA 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.

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

34. Tank you for your attention