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SHOCK CARDIOGENICO.pdf
1. SHOCK CARDIOGÉNICO
ECLS
Dr. J. A. Espinoza Huircalaf
Médico Jefe Cirugía Cardiovascular
Prof. Asistente de Cardiología
Hospital Clínico
Universidad de Chile
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4. 4
Aproximación inicial al estado de shock. Tomado de
Circulatory Shock. N Engl J Med 2013;369:1726-34.
5. Cardiogenic shock is the most severe form of acute cardiac
failure.
Generally, it is a state of life-threatening end-organ
hypoperfusion resulting from a low cardiac output state.
Hemodynamically, it is defined as persistent hypotension:
(systolic blood pressure 80-90 mm Hg or mean arterial pressure
30 mm Hg lower than baseline) with a severe reduction in
cardiac index (<1.8 L/min/m2 without support or 2.0 to 2.2
L/min/m2 with support) and adequate or elevated filling
pressure
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6. Cardiogenic shock occurs in 5% to 7% of patients presenting with
AMI and is more frequent in patients with ST-segment elevation
MI (STEMI) than non-STEMI
Mechanical complications of AMI including ventricular septal
rupture and papillary muscle rupture often also leads to
deterioration into cardiogenic shock Of these, ventricular septal
rupture continues to carry the worst prognosis.
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7. KEY POINTS
1. Despite novel technologies for treating shock patients, mortality in cardiogenic
shock remains high.
2. The incidence of etiologies of cardiogenic shock no related to AMI, particularly
acute on chronic heart failure, may be increasing, with a growing burden of
noncoronary structural heart disease.
3. A novel staging classification for cardiogenic shock has value in risk
stratification and may potentially facilitate cardiogenic shock-focused
research.
4. Before the introduction of coronary revascularization treatments for AMI,
in-hospital mortality rates from AMI-cardiogenic shock were higher than
80% !!!
5. in the decade following the widespread adoption of percutaneous coronary
intervention, estimated mortality rates from AMI-cardiogenic shock
significantly declined to roughly 50% …
6. Contemporary cohorts suggest that outcomes after AMI-cardiogenic shock
have improved, with hospital mortality of 30% to 40% …
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8. Society for Cardiovascular Angiography and Intervention (SCAI)
Stages of Shock
(1) Stage A: ‘At-Risk’ for cardiogenic shock describes a patient who is not experiencing signs or
symptoms of cardiogenic shock but is at risk for its development.
(2) Stage B: ‘Beginning’ cardiogenic shock (Pre-shock/compensated Shock) describes a
patient with clinical evidence of relative hypotension or tachycardia without hypoperfusion
(3) Stage C: ‘Classic’ cardiogenic shock is a patient with hypoperfusion that requires an initial
set of interventions (inotropes, vasopressors, or mechanical circulatory support) beyond
intravascular volume resuscitation to restore end-organ perfusion.
(4) Stage D: ‘Deteriorating’ cardiogenic shock describes a patient who has failed to stabilize
despite intense initial efforts, and further escalation is required.
(5) Stage E: ‘Extremis’ cardiogenic shock is the patient with circulatory collapse, frequently in
refractory cardiac arrest with ongoing cardiopulmonary resuscitation (CPR) and often
supported by multiple simultaneous acute interventions, including extracorporeal membrane
oxygenation (ECMO)-facilitated CPR (eCPR).
Curr Opin Cardiol 2022, 37:000–000
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9. Society for Cardiovascular Angiography and Intervention (SCAI)
Stages of Shock
Society for Cardiovascular Angiography and Intervention (SCAI) Staging Classification for patients with or at risk for
cardiogenic shock, validated by real-world cohorts.
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10. Society for Cardiovascular Angiography and Intervention (SCAI)
Stages of Shock
The Pyramid of Cardiogenic Shock
Catheter Cardiovasc Interv. 2019;1–9.SCAI clinical expert consensus statement on the classification of cardiogenic shock
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20. ECMO / ECLS
Modificación del bypass cardiopulmonar utilizado originalmente en
cirugía cardíaca, para el manejo de una falla ventilatoria y/o circulatoria
REVERSIBLE, que no responde a medidas habituales, en UCI, Pabellón,
Urgencias, Vía pública, etc...
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JACC VOL. 71, NO. 10, 2018 Han and Swain MARCH 13, 2018:1178 – 8 2
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JACC VOL. 71, NO. 10, 2018 Han and Swain MARCH 13, 2018:1178 – 8 2
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JACC VOL. 71, NO. 10, 2018 Han and Swain MARCH 13, 2018:1178 – 8 2
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JACC VOL. 71, NO. 10, 2018 Han and Swain MARCH 13, 2018:1178 – 8 2
29. CUADRO COMPARATIVO ACM
1. EL ECMO SE INSTALA EN CUALQUIER PARTE
2. PERMITE DAR SOPORTE VITAL COMPLETO: PRESIÓN Y OXIGENACIÓN
3. NO NECESITA UN PABELLÓN DE RADIOLOGÍA INTERVENCIONAL
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32. MORTALIDAD
One third of patients with AMI-cardiogenic shock will not survive
hospital discharge indicates that there are still significant
opportunities to improve outcomes …
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39. SHOCK POST CARDIOTOMÍA
• Paciente con una inadecuada performance después de
cirugía cardíaca a pesar del soporte de inótropos y balón
de contrapulsación.
• Ocurre entre el 0,2 y el 6% de los casos
• Mortalidad entre el 70 – 85%
• Incluye también a pacientes que se liberaron del bypass
cardiopulmonar, pero que presentan un síndrome de bajo
débito, en el postoperatorio temprano
● Inadecuada perfusión de órganos, a pesar de un soporte
médico máximo…
Smedira NG et al (2001) Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: survival at fi ve years.
J Thorac Cardiovasc Surg 122:99–102
Rastan AJ, Dege A, Mohr M et al (2010) Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation
for refractory postcardiotomy cardiogenic shock J Thorac Cardiovasc Surg 139:302–311
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45. ECMO venoarterial periférico con
canulación femorofemoral.
1: cánula venosa de drenaje
2: cánula arterial de retorno
3: cánula de perfusión distal del
miembro.
48. Soporte Circulatorio Mecánico
● El ECMO venoarterial puede soportar corazón y
pulmones, de manera eficiente con un costo
razonable, en tanto se precisa la razón de la
falla cardíaca
● Estrategia como puente a la recuperación,
trasplante o estrategias alternativas
● Implante
• Periférico
• Central
• Mixto
Puente a la toma de decisiones …
Pae WE Jr, Miller CA, Matthews Y, Pierce WS (1992) Ventricular assist devices for postcardiotomy cardiogenic shock. A combined registry experience. J Thorac Cardiovasc Surg 104(3):541–552;
discussion 52–53
Guyton RA, Schonberger JP, Everts PA, Jett GK, Gray LA Jr, Gielchinsky I, Raess DH, Vlahakes GJ, Woolley SR, Gangahar DM (1993) Postcardiotomy shock: clinical evaluation of the BVS 5000
biventricular support system Ann Thorac Surg 156:346–356
Akay MH, Gregoric ID, Radovancevic R, Cohn WE, Frazier OH (2011) Timely use of a CentriMag heart assist device improves survival in postcardiotomy cardiogenic shock. J Card Surg
26(5):548–552
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53. Alternative externalization of
extracorporeal life support (ECLS)
arterial and venous cannulae.
(A) Jugular tunneling of the
arterial and venous cannulae at
the jugular site, allowing sternal
closure.
(B) Externalization of the ECLS
cannulae through intercostal
spaces.
(C) Externalization of the arterial
outflow port of a veno-arterial
ECLS through a prosthetic graft
anastomosed at the aortic
prosthesis; this approach may
allow a central configuration,
sternal closure, and cannula
withdrawal in case of weaning
without reopening the sternum.
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