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Dr. Adel El Banna M.DDr. Adel El Banna M.DConsultant of Cardiac Consultant of Cardiac
SurgerySurgeryHead of Cardiac Surgery DepartmentHead of Cardiac Surgery Department
National Heart InstituteNational Heart Institute
Can you do Can you do Anything?Anything?
Acute cardiogenic shock is a Acute cardiogenic shock is a lethal condition that results lethal condition that results inin death from myocardial death from myocardial failure, arrhythmia, or failure, arrhythmia, or combinations ofcombinations of both.both.
Classic Criteria for Diagnosis of Classic Criteria for Diagnosis of Cardiogenic ShockCardiogenic Shock
1.1. Systemic HypotensionSystemic Hypotensionsystolic arterial pressure < 80 mmHgsystolic arterial pressure < 80 mmHg
2.2. Persistent HypotensionPersistent Hypotensionat least 30 minutesat least 30 minutes
3.3. Reduced Systolic Cardiac FunctionReduced Systolic Cardiac FunctionCardiac index < 1.8 x mCardiac index < 1.8 x m²/min²/min
4.4. Tissue HypoperfusionTissue HypoperfusionOliguria, cold extremities, confusionOliguria, cold extremities, confusion
5.5. Increased Left Ventricular FillingIncreased Left Ventricular FillingPulmonary capillary wedge pressure > Pulmonary capillary wedge pressure >
18 mmHg18 mmHg
CardiogenicCardiogenic ShockShock
Lethal loopLethal loop
1.1. Acute myocardial infarction:Acute myocardial infarction:
• About 7% of cases may complicate About 7% of cases may complicate with cardiogenic shock .with cardiogenic shock .
• associatedassociated with a high mortality with a high mortality [In-hospital mortality rate[In-hospital mortality rate is 47% ]. is 47% ].
• The most common causes of death The most common causes of death include pump failureinclude pump failure or arrhythmia, or arrhythmia, or both.or both.
Cardiogenic shock may result in any Cardiogenic shock may result in any of this 2 situations:of this 2 situations:
2- 2- Post-cardiotomyPost-cardiotomy • ~ ~ 1-2% of cases ( fail to come of 1-2% of cases ( fail to come of
pump)pump)• high mortality with death rates high mortality with death rates
reaching 80% in the settingreaching 80% in the setting of low of low cardiac output and need for multiple cardiac output and need for multiple high-dose inotropichigh-dose inotropic drugs .drugs .
3- 3- Inflammatory myocarditisInflammatory myocarditis about 2000 case/yr.about 2000 case/yr.
Acute Failure Sudden Onset Very Severe Possibly Isolated Reactive Therapy Poor Outcomes Likely reversable
Chronic Failure Gradual onset. Graded severity. Several co-
morbidities Proactive therapy. Reasonable
outcome. Unlikely
recoverable.More ChallengeMore Challenge
Class IClass I
1.1. IABP is recommended IABP is recommended for STEMI patients for STEMI patients when cardiogenic shock is not quickly when cardiogenic shock is not quickly reversed with pharmacological therapy. reversed with pharmacological therapy. The IABP is a stabilizing measure for The IABP is a stabilizing measure for angiography and prompt angiography and prompt revascularization.revascularization.
2.2. Intra-arterial monitoring is Intra-arterial monitoring is recommended recommended for the management of for the management of STEMI patients with cardiogenic shock.STEMI patients with cardiogenic shock.
1.1. Early revascularizationEarly revascularization, either PCI or CABG, is , either PCI or CABG, is recommended for patients recommended for patients < 75 years old< 75 years old with ST with ST elevation or new LBBB who develop shock unless elevation or new LBBB who develop shock unless further support is futile due to patient’s wishes or further support is futile due to patient’s wishes or unsuitability for further invasive care.unsuitability for further invasive care.
2.2. Fibrinolytic therapy Fibrinolytic therapy should be administered to STEMI should be administered to STEMI patients with cardiogenic shock who are unsuitable for patients with cardiogenic shock who are unsuitable for further invasive care and do not have contraindications further invasive care and do not have contraindications for fibrinolysis.for fibrinolysis.
1.1. Echocardiography should be used to evaluate Echocardiography should be used to evaluate mechanical complications unless assessed by invasivelymechanical complications unless assessed by invasively
Class IClass I
ACC/AHA Guidelines for Cardiogenic ShockACC/AHA Guidelines for Cardiogenic Shock
Class IIaClass IIa
1.1. Pulmonary artery catheter monitoring Pulmonary artery catheter monitoring can be useful can be useful for for the management of STEMI patients with cardiogenic the management of STEMI patients with cardiogenic shock.shock.
2.2. Early revascularization, either PCI or CABG, Early revascularization, either PCI or CABG, is is reasonablereasonable for selected patients > 75 years for selected patients > 75 years with ST with ST elevation or new LBBB who develop shock < 36 hours elevation or new LBBB who develop shock < 36 hours of MI and who are suitable for revascularization that is of MI and who are suitable for revascularization that is performed < 18 hours of shock. performed < 18 hours of shock.
Patients with good prior functional status who agree to Patients with good prior functional status who agree to invasive care may be selected for such an invasive invasive care may be selected for such an invasive strategy.strategy.
Hochman Circ 2003: 107:298
ACC/AHA Guidelines 2004ACC/AHA Guidelines 2004
Algorithm for native heart recovery Algorithm for native heart recovery after acute myocardial infarction:after acute myocardial infarction:
Intense antifalure therapy
Needs splintage by
assisst deviceAccepted for surgery
improved Revascularization
Mitral repaire
Volume reductionsurgery
No improvement
No contra indicationTo surgery
CardiacTransplantation
Splintage till heart recoversSplintage till heart recovers1- Postcardiotomy cardiogenic shock.2- Acute myocardial infarction
suffering cardiogenic shock in (7% of cases).
3- Acute decompensation of chronic heart failure ( arrhythmia, infarction,infection).
4- Myocarditis.5- Refractory ventricular arrhythmias.6- High risk cardiac operations.
RECENTLY:RECENTLY:
Extracorporeal1- Centrifugal pump.2- Abiomed BVS 5000.3- Thoratec device.4- Berlin heart.5- ECMO ( adult extracorporeal
memb. Oxygenator).
IntracorporealIntracorporeal1- Intra Aortic Balloon pump.2- Thoratec heart mate.3- Thoratec intracorporeal
VAD.4- Novacor N 1000 PC.5- Novacor II.6- Lion heart LVD 2000.7- Rotary pumps.8- Cardiac compression
device.
The Intra- Aortic Balloon
Intra-aortic balloon pumping is Intra-aortic balloon pumping is known to be ineffectiveknown to be ineffective in severe in severe cardiogenic shock when the systolic cardiogenic shock when the systolic aortic pressureaortic pressure cannot be augmented cannot be augmented to more than 60 or 70 mm Hg .to more than 60 or 70 mm Hg .
Contraindications to IABPContraindications to IABP
1.1.Significant aortic regurgitationSignificant aortic regurgitation
2.2.Abdominal aortic aneurysmAbdominal aortic aneurysm
3.3.Aortic dissectionAortic dissection
4.4.Uncontrolled septicemiaUncontrolled septicemia
5.5.Uncontrolled bleeding diathesisUncontrolled bleeding diathesis
6.6.Severe bilateral peripheral vascular disease uncorrectable Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgeryby peripheral angioplasty or cross-femoral surgery
7.7.Bilateral femoral-popliteal bypass grafts for severe Bilateral femoral-popliteal bypass grafts for severe peripheral vascular diseaseperipheral vascular disease
Grossman’s 2000Grossman’s 2000
Ease of Placement and Operation Ease of Placement and Operation Hemocompatible Hemocompatible No compromise to valve function No compromise to valve function Improved limb and tissue perfusion Improved limb and tissue perfusion Low Hemolysis, bleeding, and stroke Low Hemolysis, bleeding, and stroke
rates rates Restored Hemodynamics Restored Hemodynamics Improved outcomes Improved outcomes Unloading effect on the left ventricle Unloading effect on the left ventricle
A self-contained A self-contained electrohydraulic TAH.electrohydraulic TAH. Is fully implantable skin. Is fully implantable skin. Utilizes a Utilizes a transcutaneous energy transcutaneous energy transfer (TET) system and transfer (TET) system and a radiofrequency a radiofrequency communication (RF communication (RF Comm) system that allows Comm) system that allows it to be powered and it to be powered and controlled by signals controlled by signals transmitted across intact transmitted across intact skin. skin.
AbioCor total artifical heart July 2, 2001
Systolic blood pressure < 80 mmHg Systolic blood pressure < 80 mmHg {mean {mean 65mmHg}.65mmHg}.
Pulmonary capillary wedge >20 mmHgPulmonary capillary wedge >20 mmHg Systemic vasculare resistance > 2100 Systemic vasculare resistance > 2100
dynes.sec/cmdynes.sec/cm55
urine output < 20 ml/hr urine output < 20 ml/hr { on diuretics}.{ on diuretics}. Cardiac output < 2 lit /min /mCardiac output < 2 lit /min /m22 {{on maximum on maximum
inotropicinotropic support}.support}.
Right ventricular failure.Right ventricular failure.
Clinical right-sided congestive Clinical right-sided congestive symptoms. symptoms.
Patients with clear documentation Patients with clear documentation of poor right ventricular EF.of poor right ventricular EF.
Fixed pulmonary hypertension Fixed pulmonary hypertension above 60 mm Hg systolic.above 60 mm Hg systolic.
these patients better suited for transplantationthese patients better suited for transplantation. .
The use of VAD for cardiogenic shock hasThe use of VAD for cardiogenic shock has received received a considerable amount of attention with varying a considerable amount of attention with varying degreesdegrees of survival based on: of survival based on:
1. Timing of insertion.2. Age. 3. The presence of comorbidities.
4. Duration of support.5. Experience of the implanting center and surgeon.
Patients successfully bridged to Patients successfully bridged to recovery were those thatrecovery were those that had had ancillary procedures done at the ancillary procedures done at the time of VAD insertion ortime of VAD insertion or shortly shortly thereafter (ie, concomittent PCI thereafter (ie, concomittent PCI or surgery).or surgery).
Hochman et al, NEJM 1999; 341:625.
Hochman et al, NEJM 1999; 341:625.
Conclusion :Conclusion :
Collaboration between cardiac Collaboration between cardiac surgery and cardiology,surgery and cardiology, in the form in the form of mechanical support and of mechanical support and percutaneous interventionspercutaneous interventions (ie, (ie, coronary angioplasty and ablative coronary angioplasty and ablative therapy) can be accomplishedtherapy) can be accomplished with with the goal of restoring and the goal of restoring and maintaining native heart recovery.maintaining native heart recovery.
We favor an aggressive We favor an aggressive approach to promote approach to promote myocardial recovery,myocardial recovery, and we and we utilize the surgical and medical utilize the surgical and medical resources to accomplishresources to accomplish this end. this end.
In the absence of recovery, In the absence of recovery, transplantation of permanenttransplantation of permanent VAD VAD therapy is appropriate.therapy is appropriate.
1.1. Insert an Intra Aortic Balloon.Insert an Intra Aortic Balloon.
2.2. Insertion of an LV assisst device.Insertion of an LV assisst device.
3.3. Perform urgent Myocardial Perform urgent Myocardial revascularization.revascularization.
4.4. Surgical correction of Ischemic Surgical correction of Ischemic complication complication
ie, VSD, Pseudoaneurysm.ie, VSD, Pseudoaneurysm.
First Generation Hybrid Cardiac theaterFirst Generation Hybrid Cardiac theater
