How to manage the shocked patients after revascularization

Cardiogenic shock complicanting AMI From pharmacology to new mechanical supports How to manage the shocked patients after revascularization Antonio M...
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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

s h

s

s s s s H h s sh s H h s s hs H h H h Hh h s h s s s s

h H

s

H= hub cardiochirurgico h= sede di emodinamica diagnostico/interventistica s= spoke: Unità Terapia Intensiva Cardiologica

s

s

h s h s

h s s

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

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