This slideset is related to the concept of ventricular unloading

1. ROLE OF HEMODYNAMIC
SUPPORT IN STEMI : WHEN
AND HOW
DR. SOMNATH MUKHOPADHAY

3. RECOMMENDATION FOR MANAGEMENT OF
CARDIOGENIC SHOCK IN STEMI

4. RECOMMENDATION FOR MANAGEMENT OF
CARDIOGENIC SHOCK IN STEMI

6. PHILOSOPHY : TIME TO RETHINK
• DTB <90 MIN IS NOT ASSOCIATED WITH IMPROVED IN-HOSPITAL MORTALITY,
SPECIALLY IN AWMI & CS.
• DESPITE TIMELY REPERFUSION 10% MORTALITY IN INDEX HOSPITALIZATION &
76% OF THOSE WHO SURVIVE, PROGRESS TO CHF IN NEXT 5 YEARS.
• MYOCARDIAL REPERFUSION: DOUBLE EDGED SWORD: ISCHEMIA REPERFUSION
INJURY.
• CRISP-AMI TRIAL : 40% LV INJURED, QUANTIFIED BY CMR, WITHIN 1 WK OF
SUCCESSFUL REPERFUSION.

9. PHARMACOLOGICAL MANAGEMENT
• PROMPT MANAGEMENT OF HYPOTENSION AND HYPOPERFUSION.
• VOLUME STATUS : EMPIRIC IV 250 ML ISOTONIC SALINE PRIOR TO RHC IF NO
EVIDENCE OF PULMONARY CONGESTION.
• RVMI: DIFFERENT BALL GAME.
• INOTROPE : NE PREFERRED OVER DOPAMINE.
• DOBUTAMINE: LOW CARDIAC INDEX, HIGH PCWP, BORDERLINE LOW BP WITHOUT
SEVERE HYPOTENSION.
• NON HYPOTENSIVE : DOBUTAMINE PLUS VASODILATOR.

11. IABP : MECHANISM
1. SCALE OF DIASTOLIC PRESSURE AUGMENTATION
2. SCALE OF REDUCTION IN SYSTOLIC PRESSURE
3. DEGREE OF BLOOD VOLUME DISPLACEMENT
4. TIMING OF BALLOON INFLATION AND DEFLATION.
ADVANTAGES : EASE OF INSERTION, RELATIVELY LOW COST, GLOBAL FAMILIARITY
OF THE TECHNOLOGY.

12. IABP IN STEMI : ROUTINE USE IS NOT
RECOMMENDED.
1. HEMODYNAMICALLY UNSTABLE, CIRCULATORY SUPPORT REQUIRED TO PERFORM CAG F/B
PTCA OR SURGERY.
2. CARDIOGENIC SHOCK UNRESPONSIVE TO MEDICAL MANAGEMENT
3. REFRACTORY ISCHAEMIA UNRESPONSIVE TO TREATMENT OR WAITING FOR DEFINITIVE
REVASCULARIZATION.
4. BENEFIT MAY EXIST IN MECHANICAL DEFECT : MR, VSD.
TAMI TRIAL : LESS RE-OCCLUSION, MORE MORTALITY, ? SELECTION BIAS.
PAMI II TRIAL : NO DIFFERENCE IN DEATH, RE-INFARCTION, IRA RE-OCCLUSION, STROKE, NEW
HF OR VA.
IABP SHOCK II TRIAL: NO ALL CAUSE MORTALITY BENEFIT OR LONG TERM MORTALITY BENEFIT.

13. IABP SHOCK II SCORE

14. IMPELLA IN STEMI
• CATHETER MOUNTED AXIAL FLOW DEVICE, DEPLOYED INTO LV ACROSS AV.
• TRANSFERS KINETIC ENERGY FROM A CIRCULATING IMPELLER TO THE BLOOD IN LV RESULTING
CONTINUOUS FLOW ACROSS AV.
• ISAR-SHOCK : FAILED TO SHOW DIFFERENCES IN MORTALITY, BLEEDING OR DISTAL LIMB ISCHAEMIA.
• EUROSHOCK REGISTRY (N=120): 30 D MORTALITY HIGH BUT IT LIKELY REFLECTS LAST RESORT
CHARACTER OF IMPELLA 2.5 IN POOR HEMODYNAMICS AND GREATER IMMINENT RISK OF DEATH.
• IMPRESS : NO OUTCOME DIFFERENCES OR MORTALITY DIFFERENCE (50% BOTH) WHEN COMPARED
WITH IABP. EXCESS MAJOR BLEEDING.
• USPELLA REGISTRY: EARLY INITIATION OF HEMODYNAMIC SUPPORT PRIOR TO PCI WITH IMPELLA
2.5 IS ASSOCIATED WITH MORE COMPLETE REVASCULARIZATION AND IMPROVED SURVIVAL IN THE
SETTING OF REFRACTORY CS COMPLICATING AN AMI.

15. TANDEMHEART IN STEMI
• EXTRACORPOREAL CENTRIFUGAL FLOW PUMP THAT BYPASSES OXYGENATED
BLOOD FROM LA TO DESCENDING AORTA VIA 21FR TRANSSEPTAL CANNULA IN
LA & ARTERIAL OUTFLOW CANNULA IN FA.
• IN ASCENDING AORTA, INCREASED AFTERLOAD RESTRICTS LV UNLOADING. IN
DESCENDING AORTA, INCREASED AFTERLOAD IS ALLEVIATED BY RETROGRADE
PERFUSION OF MESENTERIC & RENAL ARTERIES AS WELL AS GREAT VESSELS OF
AORTIC ARCH, WHICH DECREASES LVSW.
• NO MORTALITY BENEFIT WAS SEEN IN DIFFERENT SMALL TRIALS.

16. VA-ECMO IN STEMI
• IT REMOVES DEOXYGENATED VENOUS BLOOD, CIRCULATES IT THROUGH
OXYGENATOR & EXTRA-CORPOREAL CENTRIFUGAL FLOW PUMP AND RETURNS
OXYGENATED BLOOD TO ARTERIAL CIRCULATION. INFLOW CANNULA: RA OR
ACROSS SVC & IVC. OUTFLOW CANNULA FA OR SUBCLAVIAN ARTERY.
• REDUCED RV & LV VOLUMES, INCREASED MAP. MAY BE A/W INCREASED LV
PRESSURE.
• CONCOMITANT VENT: INOTROPES, CONCOMITANT IABP OR LV-IMPELLA OR LA-
CANNULA.

17. LIMITATION OF VA-ECMO IN STEMI
• POSSIBILITY FOR LV DISTENTION & INCREASED LV STROKE WORK.
• POTENTIALLY HIGHER RISK FOR BLEEDING.
• RISK OF VASCULAR INJURY, LIMB ISCHAEMIA & INSUFFICIENT UPPER BODY
OXYGENATION IN CASES OF RELATIVELY PRESERVED LV SYSTOLIC FUNCTION.
EUROSHOCK TRIAL: NON-SIGNIFICANT REDUCTION IN 30 D MORTALITY AND EVEN
1 YR MORTALITY WITH STANDARD THERAPY + ECMO THAN STANDARD THERAPY
ONLY.

19. RVMI
• PAPI: HEMODYNAMIC INDICATOR OF RV FAILURE IN IWMI AS WELL AS POST-
LVAD.
• SHOCK TRIAL: RV DOMINANT CS HAD SIMILAR MORTALITY AS LV DOMINANT CS.
• SIGNIFICANTLY HIGHER IN-HOSPITAL MORTALITY, CS, VA & ADVANCED AV
BLOCK IF MI INVOLVED RV : SEEN IN DIFFERENT META-ANALYSES.
• SURGICAL RVAD, ECMO, ATRIAL SEPTOSTOMY, IMPELLA RP, TANDEMHEART
PROTECT DUO CANNULA.
• RECOVER RIGHT TRIAL: IMPELLA RP WAS SAFE, EASY TO DEPLOY & RELIABLY
RESULTED IMMEDIATE HEMODYNAMIC BENEFIT IN LIFE THREATENING RV
FAILURE.