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Abbas Ferdosi M.D. Oct. 2014
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
Abbas Ferdosi M.D. Oct. 2014
- 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
Abbas Ferdosi M.D. Oct. 2014
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%
ResultsSchuechtermann Clinic Bypass surgery in acute myocardial infarction (<24h) 1/2004 - 09/2006 n = 321 (30-day mortality was 10%)
Abbas Ferdosi M.D. Oct. 2014
• Intra Aortic Balloon Pump (IABP)
• Extra Corporeal Membrane Oxygenation (ECMO)
• Impella
Mechanical Option
Abbas Ferdosi M.D. Oct. 2014
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.
IABP
Abbas Ferdosi M.D. Oct. 2014
Intra-Aortic Balloon Pump (IABP) functional principle
Intra-Aortic Balloon-counterpulsation
Abbas Ferdosi M.D. Oct. 2014
IABP functional principle
Diastole
- Balloon inflates- Increased blood flow to coronaries
Systolie
- Balloon deflates- Afterload is reduced- Increased forward blood flow
Abbas Ferdosi M.D. Oct. 2014
Effects of IABP Therapy
Coronary perfusion
Stroke Volume
Ventricular Emptying
Cardiac output
LV Workload
Myocardial oxygen Demand
Abbas Ferdosi M.D. Oct. 2014
IABP- Indication
- Cardiogenic shock
- Intractable angina pectoris
- Low cardiac output after CABG
- Support for diagnostic, percutaneous revascularisations and
interventional procedures
- Others…
Abbas Ferdosi M.D. Oct. 2014
Contraindication
- Severe aortic regurgitation
- Aortic dissection
- Aneurysm of the abdominal or thoracica aorta
- Severe calcific aorto- iliac disease or peripheral vascular
Abbas Ferdosi M.D. Oct. 2014
CONCLUSIONSThe 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.)
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
Abbas Ferdosi M.D. Oct. 2014
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.
Abbas Ferdosi M.D. Oct. 2014
ECMO• The blood is than returned to the patient via a central vein
or an artery.
Abbas Ferdosi M.D. Oct. 2014
ECMO function
• Reduction of preload and afterload
• Oxygenation of the blood
Abbas Ferdosi M.D. Oct. 2014
ECMO indication
- Cardiogenic shock
- Post cardiotomy
- Bridge to HTX/VAD
- Graft failure
- Myocarditis
- ECMO-CPR
Abbas Ferdosi M.D. Oct. 2014
ECMO Contraindications
- Severe calcific aorto- iliac disease or peripheral vascular
- Multi-Organ Failure
- End-stage Disease
Abbas Ferdosi M.D. Oct. 2014
- 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
Abbas Ferdosi M.D. Oct. 2014
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
Impella
Abbas Ferdosi M.D. Oct. 2014
Impella® Controller (AIC)
Impella Controller (AIC) for monitoring and control of the Impella pump and the purge system.
Abbas Ferdosi M.D. Oct. 2014
Promotion of blood
Motor Impeller cannula
- 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
HCS-PP00022-006 rA EU
Abbas Ferdosi M.D. Oct. 2014
Impella® Circulatory Support Platforms
Impella 2.5 Impella CP Impella 5.0 Impella LDFlow Rate (L/min) 2.5 3.7 – 4.0 5.0 5.0
Circulatory Support Partial Partial - High High-flow High-flow
Catheter Size 9 Fr 9 Fr 9 Fr 9 Fr
Pump Size 12 Fr 14 Fr 21 Fr 21 Fr
Insertion Method Percutaneous Percutaneous Arterial Cut down Surgical Insertion
Impella
Abbas Ferdosi M.D. Oct. 2014
Impella ON
Impella increases perfusion
Impella OFF
Under-perfused area
Improvement in Myocardial Perfusion with Impella Support (Tc-99 MIBI Imaging)
Increased Myocardial Blood Flow, Aqel et al. (2009)
MicrovascularResistance (MR)
Aortic Pressure
(AOP)
Myocardial Protection … O2 Supply
Blood Flow(Coronary Arteries & Microvasculature)
AOP
MRa
Abbas Ferdosi M.D. Oct. 2014
Unloading Reduces Infarct Size…Impella vs IABP Meyns et al., JACC (2003)
Myocardial Protection … O2 Supply
Abbas Ferdosi M.D. Oct. 2014
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.
Abbas Ferdosi M.D. Oct. 2014
Conclusion
Early mechanical support of the heart reduces
mortality in cardiogenic shock.