Cardiogenic shock complicanting AMI From pharmacology to new mechanical supports
How to manage the shocked patients after revascularization Antonio Manari U.O. Cardiologia Interventistica Reggio Emilia Firenze 2011
Il Dr. Antonio Manari dichiara di non avere potenziali conflitti di interessa riguardo agli argomenti oggetto della presentazione.
Shock cardiogeno
Perdita Perdita di massa della massa ventricolare ventricolare > 40%>40%
Incidenza di shock cardiogeno in pazienti avviati a p-PCI 16 14
11,8
12 10
9,5
8,6 7,5
8 6 4 2 0 Brodie, 2007
NRMI, 2005
Kalla, 2006
REAL, 2008
Shock Trial Registry
Babaev JAMA, 2005
Cardiogenic shock and heart failure post-percutaneous coronary intervention in STEMI: observation from APEX-AMI French JK et al. Am Heart J, 2011
(median) 6 hours IQR (3,9-28,3)
(median) 2,6 days IQR (1,0-16,6)
Diagnostic algorithm for patients with acute heart failure
Acute LV failure after PPCI
Are there non-cardiac causes of heart failure?
• Haemorrage • Pulmonary embolism • Sepsis • Drugs
YES
Non cardiogenic NO
Cardiogenic
Are there mechanical complications of STEMI? YES NO
Are there other cardiac precipitating factors? • Arrhythmias Saia F, Am Heart J 2010
Are there mechanical complications of STEMI?
Diagnostic algorithm for patients with acute heart failure YES NO
Are there other cardiac precipitating factors? • Arrhythmias
YES
• Valvular disease • Right ventricular failure
NO
“Pure” LV failure
Are pre-load and after-load adequate?
inotropic support, agents for pre- and after-load reduction
NO YES
Is acute LV failure reversible? YES NO Figure 1.
Saia F, Am Heart J 2010
Intra-aortic balloon pump (IABP) •augments coronary diastolic blood flow •reduces LV afterload and aortic impedance
The IABP should be inserted before angiography in patients with haemodynamic instability (particularly those in cardiogenic shock and with mechanical complications). An IABP should not be used in patients with aortic insufficiency or aortic dissection.
A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines ? Krischan DS et al; Eur Heart J, 2009
The overall effect estimate in the thrombolysis cohorts favoured IABP therapy, whereas the overall effect estimate in the primary PCI cohorts disfavoured IABP therapy. IABP therapy may have been preferentially given to patients in worse condition. Therefore, the results of this analysis must be interpreted cautiously.
The principal limitation of IABP is the lack of active circulatory support
Sistemi di assistenza ventricolare utilizzabili nel Cath Lab
Cyrus T et al. Cath Cardiovasc Interv. 2010
Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a metaanalysis of controlled trials Cheng JM, den Uil CA, Hoeks SE, van der Ent M, Jewbali L, Ron T. van Domburg RT, Serruys P.
Eur Heart J, 2009
Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a metaanalysis of controlled trials Cheng JM, den Uil CA, Hoeks SE, van der Ent M, Jewbali L, Ron T. van Domburg RT, Serruys P.
Eur Heart J, 2009
Acute Heart Failure after pPCI
Saia F, Am Heart J 2010
Mechanical circulatory assistance other than an IABP can be offered at tertiary centres with an institutional programme for mechanical assist therapy if the patient continues to deteriorate and cardiac function cannot maintain adequate circulation to prevent end-organ failure
11 Cath Lab con programma di p-PCI H/24 6 Cardiochirurgie 1 Centro Trapianti
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H= hub cardiochirurgico h= sede di emodinamica diagnostico/interventistica s= spoke: Unità Terapia Intensiva Cardiologica
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Paziente con shock cardiogeno
Osservazione 3-6 ore
Tempistiche e Strategie
Variazioni dell’emodinamica Equilibrio acido-base Scambi respiratori
Centralizzazione CC riferimento (Area Vasta): •LVAD •Rivascolarizzaione “completa” •Interfaccia con Centro Trapianti (protocolli predefiniti) Centralizzazione Centro Trapianti •TC •VAD para/intracorporei
bridge to recovery bridge to heart trasplantion destination therapy
The principal limitation of IABP is the lack of active circulatory support
bridge to recovery bridge to heart destination therapy
Prima generazione: flusso pulsatile
Seconda generazione: flusso continuo