Patient in Cardiogenic Shock : When to Call the Surgeon?

1. Patient in Cardiogenic Shock: When to Call the Surgeon? Dr. Adel El Banna M.D Consultant of Cardiac Surgery Head of Cardiac Surgery Department National Heart Institute

2. Can you do Anything?

3. Acute cardiogenic shock is a lethal condition that results indeath from myocardial failure, arrhythmia, or combinations ofboth.

4. Classic Criteria for Diagnosis of Cardiogenic Shock • Systemic Hypotension • systolic arterial pressure < 80 mmHg • Persistent Hypotension • at least 30 minutes • Reduced Systolic Cardiac Function • Cardiac index < 1.8 x m²/min • Tissue Hypoperfusion • Oliguria, cold extremities, confusion • Increased Left Ventricular Filling • Pulmonary capillary wedge pressure > 18 mmHg

5. Lethal loop Cardiogenic Shock

7. Cardiogenic shock may result in any of this 2 situations: • Acute myocardial infarction: • About 7% of cases may complicate with cardiogenic shock . • associatedwith a high mortality [In-hospital mortality rateis 47% ]. • The most common causes of death include pump failureor arrhythmia, or both.

8. 2- Post-cardiotomy • ~ 1-2% of cases ( fail to come of pump) • high mortality with death rates reaching 80% in the settingof low cardiac output and need for multiple high-dose inotropicdrugs . • 3- Inflammatory myocarditis • about 2000 case/yr.

9. Heart failure • 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 Challenge

10. ACC/AHA Guidelines for Cardiogenic Shock Class I • IABP is recommended for STEMI patients when cardiogenic shock is not quickly reversed with pharmacological therapy. The IABP is a stabilizing measure for angiography and prompt revascularization. • Intra-arterial monitoring is recommended for the management of STEMI patients with cardiogenic shock.

11. ACC/AHA Guidelines for Cardiogenic Shock Class I • Early revascularization, either PCI or CABG, is recommended for patients < 75 years old with ST elevation or new LBBB who develop shock unless further support is futile due to patient’s wishes or unsuitability for further invasive care. • Fibrinolytic therapy should be administered to STEMI patients with cardiogenic shock who are unsuitable for further invasive care and do not have contraindications for fibrinolysis. • Echocardiography should be used to evaluate mechanical complications unless assessed by invasively

12. ACC/AHA Guidelines for Cardiogenic Shock • Class IIa • Pulmonary artery catheter monitoring can be useful for the management of STEMI patients with cardiogenic shock. • 2. Early revascularization, either PCI or CABG, is reasonable for selected patients > 75 years with ST elevation or new LBBB who develop shock < 36 hours of MI and who are suitable for revascularization that is performed < 18 hours of shock. • Patients with good prior functional status who agree to invasive care may be selected for such an invasive strategy.

13. ACC/AHA Guidelines 2004 Hochman Circ 2003: 107:298

14. Algorithm for native heart recovery after acute myocardial infarction:

15. What can we offer in such patients?

16. ORIGINALLY:Bridging till transplantationThe traditional indication for VAD support was refractory cardiac failure in patients on the schedule list for heart transplantation.

17. RECENTLY: Splintage till heart recovers 1- 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.

18. Types of LVAD Extracorporeal 1- Centrifugal pump. 2- Abiomed BVS 5000. 3- Thoratec device. 4- Berlin heart. 5- ECMO ( adult extracorporeal memb. Oxygenator). Intracorporeal 1- Intra Aortic Balloon pump. 2- Thoratec heart mate. 3- Thoratecintracorporeal VAD. 4- Novacor N 1000 PC. 5- Novacor II. 6- Lion heart LVD 2000. 7- Rotary pumps. 8- Cardiac compression device.

19. The Intra- Aortic Balloon

20. Intra-aortic balloon pumping is known to be ineffectivein severe cardiogenic shock when the systolic aortic pressurecannot be augmented to more than 60 or 70 mm Hg .

21. Contraindications to IABP • Significant aortic regurgitation • Abdominal aortic aneurysm • Aortic dissection • Uncontrolled septicemia • Uncontrolled bleeding diathesis • Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgery • Bilateral femoral-popliteal bypass grafts for severe peripheral vascular disease Grossman’s 2000

22. The Impella 2.5

23. The Impella 2.5 • Ease of Placement and Operation • Hemocompatible • No compromise to valve function • Improved limb and tissue perfusion • Low Hemolysis, bleeding, and stroke rates • Restored Hemodynamics • Improved outcomes • Unloading effect on the left ventricle

24. The AbioCor total artifical heart(ABIOMED, Inc., Danvers, MA) • A self-contained electrohydraulic TAH. • Is fully implantable skin. • Utilizes a transcutaneous energy transfer (TET) system and a radiofrequency communication (RF Comm) system that allows it to be powered and controlled by signals transmitted across intact skin. AbioCor total artifical heartJuly 2, 2001

25. Patient selection for an assist device: • Systolic blood pressure < 80 mmHg {mean 65mmHg}. • Pulmonary capillary wedge >20 mmHg • Systemic vasculare resistance > 2100 dynes.sec/cm5 • urine output < 20 ml/hr { on diuretics}. • Cardiac output < 2 lit /min /m2{on maximum inotropicsupport}. • Right ventricular failure.

26. Which patient should avoid surgery? • Clinical right-sided congestive symptoms. • Patients with clear documentation of poor right ventricular EF. • Fixed pulmonary hypertension above 60 mm Hg systolic. these patients better suited for transplantation.

27. The use of VAD for cardiogenic shock hasreceived a considerable amount of attention with varying degreesof survival based on: Timing of insertion. Age. The presence of comorbidities. Duration of support. Experience of the implanting centerand surgeon.

28. Patients successfully bridged to recovery were those thathad ancillary procedures done at the time of VAD insertion orshortly thereafter (ie, concomittent PCI or surgery).

32. Hochman et al, NEJM 1999; 341:625.

33. Hochman et al, NEJM 1999; 341:625.

34. Conclusion : Collaboration between cardiac surgery and cardiology,in the form of mechanical support and percutaneous interventions(ie, coronary angioplasty and ablative therapy) can be accomplishedwith the goal of restoring and maintaining native heart recovery.

35. We favor an aggressive approach to promote myocardial recovery,and we utilize the surgical and medical resources to accomplishthis end. In the absence of recovery, transplantation of permanentVAD therapy is appropriate.

36. Role of the surgeon in patient’s with Cardiogenic shock • Insert an Intra Aortic Balloon. • Insertion of an LV assisst device. • Perform urgent Myocardial revascularization. • Surgical correction of Ischemic complication ie, VSD, Pseudoaneurysm.

37. First Generation Hybrid Cardiac theater

38. Thank you