PCI & AimRadial 2018 | Treating Cardiogenic Shock with Impella with Escalation to ECMO - Ramon Quesada
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PCI & AimRadial 2018 | Treating Cardiogenic Shock with Impella with Escalation to ECMO - Ramon Quesada
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PCI & AimRadial 2018 | Treating Cardiogenic Shock with Impella with Escalation to ECMO - Ramon Quesada
- 1. Ramon Quesada,MD,FACP,FACC,FSCAI Medical Director Structural Heart,Complex PCI & Cardiac Research Miami Cardiac & Vascular Institute, Miami, Florida Clinical Associate Professor of Medicine, Florida International University Herbert Wertheim School of Medicine Treating Cardiogenic Shock with Impella with Escalation to ECMO TEACH II ACC 2018
- 2. HISTORY 56 year old police officer with premature CAD and 19 prior stents; EF 53% Presented for elective cholecystectomy off DAPT for 5 days In preop developed chest pain, bradycardia and hypotension: HR 50s, BP 80/60
- 3. Pressure-Volume Relations in Acute CGS LVP and AoP Pressure-Volume CGS Defined by: ↓BP ↓SV and CO Caused by: ↓Contractility Associated with: ↑PCWP ↑CVP
- 4. INITIAL MANAGEMENT In cath lab patient had multiple rounds VT/VF requiring defibrillation, intubation Transvenous pacing wire for CHB Started on lidocaine and amiodarone Started on norepinephrine, dobutamine Impella CP placed
- 5. Impact of LVAo MCS on Hemodynamics and Energetics Pressure-Volume LVP and AoP ↓ Peak LVP ↓ Preload ↑ AoP ↓ LVP LV-Ao Uncoupling
- 6. AHHH Srihari S. Naidu Circulation. 2011;123:533-543 Copyright © American Heart Association, Inc. All rights reserved. MYOCARDIAL ENERGETICS
- 7. Impact of LVAo MCS on Hemodynamics and Energetics Pressure-Volume PVA-MVO2 (ml O2/min) ↓ Peak LVP ↓ Preload ↓ PVA ↓ MVO2
- 8. Angiogram of Left Coronaries
- 9. LCx Stent (3.0X28mm Synergy) Required Guideliner Support
- 11. RCA Angiogram
- 13. ESCALATION OF SUPPORT Despite restoration of perfusion, refractory arrhythmias continued V-A ECMO circuit initiated TEE – EF 15%
- 14. Adding V-A ECMO to Impella Impella alone Pressure-Volume LVP and AoP
- 15. MANAGEMENT Arrhytmias resolved after ECMO Patient transferred to CCU off of pressors Arrangements made for transfer to HF/Tx center for possible VAD/transplant listing Prior to transfer – good UOP, stable renal function, normal LFTs, no recurrent arrhythmia
- 16. DEVICE WEANING Impella removed after 3 days ECMO weaned after 7 days Approx 3 week hospitalization, then discharged to inpatient rehab Disharged to home 52 days after first presentation for elective surgery Most recent EF 35% Last seen 8/15/17
- 17. Impact of Weaning IMPELLA First Impella alone
- 18. KEY POINTS Lv->Ao MCS: decrease peak LVP and preload Lose isovolumic phases because device is draining the heart throughout the cardiac cycle LV-Ao uncoupling Decrease myocardial energy consumption
- 19. KEY POINTS RA->Ao MCS: increase afterload and preload Increase aortic and LV pressure Increase myocardial energy consumption Need to decompress the ventricle
- 20. SUMMARY With acute hemodynamic compromise – Restore normal hemodynamics – Minimize LV filling pressure – Minimize oxygen consumption – Restore perfusion Different MCS options have different effects on hemodynamics and energetics Escalation of support based on response to initial intervention
Editor's Notes
- A, PVA as a measure of oxygen consumption per beat. B, PVA represents the sum of stroke work (SW) and potential energy (PE). C, Unloading can occur by decreasing the area within the pressure-volume loop or shifting the loop leftward.