Cardiogenic shock From ECMO to percutaneous VADs

Shinya UnaiStaff Surgeon

Thoracic and Cardiovascular Surgery

Cleveland Clinic

Disclosures

• None

Outline

• Mechanical support for cardiogenic shock

• Unloading the ventricle

• High risk cardiac surgery

43yo maleAMI PCI to LAD

How do we support?

IABP/inotropes, C.I 1.4, VT, FiO2 100%

Aortic Counterpulsation

IABP

LV

Impella2.5/CP/5.0

TandemHeart

Centrimag

RV

Impella RP

Protek Duo

Centrimag

BiV

Impella RP + 5.0

Centrimag

Heart/Lung

ECMO

Centrimag

Long Term

Support

HeartMateII

HeartMateIII

HeartWare

Total Artificial Heart

Long-term options with IABP

Long-term options with IABP

Aortic Counterpulsation

IABP

LV

Impella2.5/CP/5.0

TandemHeart

Centrimag

RV

Impella RP

Protek Duo

Centrimag

BiV

Impella RP + 5.0

Centrimag

Heart/Lung

ECMO

Centrimag

Long Term

Support

HeartMateII

HeartMateIII

HeartWare

Total Artificial Heart

Aortic Counterpulsation

IABP

LV

Impella2.5/CP/5.0

TandemHeart

Centrimag

RV

Impella RP

Protek Duo

Centrimag

BiV

Impella RP + 5.0

Centrimag

Heart/Lung

ECMO

Centrimag

Long Term

Support

HeartMateII

HeartMateIII

HeartWare

Total Artificial Heart

Aortic Counterpulsation

IABP

LV

Impella2.5/CP/5.0

TandemHeart

Centrimag

RV

Impella RP

Protek Duo

Centrimag

BiV

Impella RP + 5.0

Centrimag

Heart/Lung

ECMO

Centrimag

Long Term

Support

HeartMateII

HeartMateIII

HeartWare

Total Artificial Heart

CentriMag

1953 Mayo-Gibbon pump

Reperfuson cannula

Venous

Arterial

VA ECMO for Cardiogenic Shock

Pro’s• Quick

• Bedside application

• Minimally invasive

• Biventricular support

• Pulmonary support

• Time to evaluate

Con’s• Non-pulsatile

• Limb ischemia

• LV distension

• Pulmonary edema

• Coronary perfusion

• LV/Aortic thrombus

• Cerebral hypoxia

VA ECMOPulmonary edema

Increased afterload +

LV standstill

LV distension

IABPInotropes

Anticoagulation

LV vent

Septostomy

Pulmonary

edema

LV thrombus

Apical

cannulation

Impella

(EC-Pella)

Impella 5.0 placement

Cardiogenic shock with

cardiopulmonary collapse

Percutaneous

VA ECMO

+/- IABP

Wean VA ECMO

8Fr Reperfusion

Sheath

Continued VA

ECMO+Impella support

5.0 Axillary Impella

(EC-Pella)

SHOCK TeamVA (VAV) VV ECMO

Wean VA ECMO,

Add Impella RP

Permanent LVAD

Heart transplant

Eventually LVAD implant

• Discharged from acute rehab

• Feeling “pretty good”

• Walking, denies SOB

10% improvement with revascularization

Hochman JS et al. NEJM 1999; 341:625-634.

15% long-term improvement

Reynolds H R , Hochman J S Circulation

2008;117:686-697

Can we do better?

• Hemodynamic support

• Unloading

Hemodynanmic effect of Impella

Coronary

Perfusion

Microvascular

Resistance

LVEDP and LVEDV

O2 Demand

Unloading to Myocardial Recovery

O2 Supply

Mechanical

WorkWall

Tension

Cardiac Power Output

Flow

End Organ Perfusion

MAP

5X Reduction in Infarct Size

Infarct

with offloading

Infarct

Swine LAD Occlusion Model

Without off-loading With off-loading Kapur, JACC HF, 2015

Left Ventricular Unloading: Timing

Esposito, JACC, 2018

Impella pre-PCI associated with improved survival in AMI/CGS

1. Abiomed Impella Quality (IQ) Database, US AMI/CGS Apr 2009– Jan 2017. Survival to device explant. Danvers, MA: Abiomed.

2. O’Neill et al., J Int Cardiol 2014;27:1-11. Survival to hospital discharge

40yo male, 8.6cm LVEDD

High risk Cardiac Surgery

• Hemodynamics (CI<2.0, PAPi<1.0)

• Decompensated HF

• Contractile reserve• Frailty

• End-organ dysfunction

• Viability, Target

• Porcelain aorta, severe MAC, multi redo…

Post-Cardiotomy Cardiogenic Shock

• 0.2-9%, 0-75% mortality

• risk in low EF

• high-dose inotrope

• long CPB0

20

40

60

80

100

Amount of Inotropic Support

Peri

op

era

tive M

ort

ality

(%

)

Effect of LVEF

0

5

10

15

20

25

30

mortality CVA RF Vent

EF < 25 25 - 35 35 - 45Shahian, ATS, 2009.

CCF High Risk Evaluation

High Risk CABG/Valve(targets, EF, viability; STS score)

High RiskTemporary MCS support

Recovery-only

? CMS DT

criteria

? UNOS BTT

criteria

Low - Moderate RiskUnlikely to need support

Ischemic: viability,

wall thickness,

ischemia

Contractile reserve

1. ECHO: LVEDD(<7.5), RV

2. RHC: CI, PAPi

3. PET/cMRI/Dobutamine stress

4. HF Cardiology

5. Social work evaluation

6. AHFTC adjudication

Preoperative Optimization

• Swan-guided inotropes, vasodilator therapy

• Possible pre-operative temporary MCS

Operative Steps

10mm graft

Vessel loops left in

for removal

Right axillary 10mm graft

Standard cannulation for CPB

Advance Impella after cross clamp off

Gain access across aortic valve using TEE and floroscopy

Post op course

Impella-Assisted Revascularization

• High risk CABG: 3-7day recovery (>48hr)

• High-risk PCI- Normal EF: PCI with femoral Impella CP

- Low EF: Impella 5.0 1 day before PCI, 3-7day recovery (>48hr)

Impella-Backup for high risk cardiac surgery

• LF/LG AS with no/low contractile reserve

• Severe AI with low EF

• Severe FMR with low EF

Recent Paradigm Shifts

• Postoperative IABP Axillary 5.0 Impella- Completely wean inotropes/pressors

- Early extubation/ambulation

- Lower ICU/total LOS, overall better outcomes

Conclusions

• Multidisciplinary, shock team approach

• Early mechanical support with LV unloading

• Impella use for PCI and high risk surgery

• Minimal use of inotropes

improved outcomes!