Postcardiotomy Cardiogenic

Shock: Optimizing Outcomes

AATS 2012, Adult Cardiac Surgery Symposium

Daniel Goldstein MD FACS FACCAssociate Professor

Vice Chair, Dept. Cardiothoracic Surgery

Disclosures

� Thoratec Inc., Medical Advisory Board

� Terumo, Chair, AEC, DuraHeart BTT Trial

� Berlin Heart Inc., Medical Advisory Board� Berlin Heart Inc., Medical Advisory Board

� Site PI: HW BTT/DT Trials, ROADMAP, REVIVE-

IT

� Will NOT discuss unapproved devices

Goals - PCCS

� Definition, epidemiology, prognosis

� Profile: hemodynamic, pharmacologic, clinical

� IABP: not a VAD� IABP: not a VAD

� Mechanical support options: what, how, when

� PCCS in community: How can you optimize

patient for transfer to VAD/Transplant center?

Limitations

� Infrequent (0.2-3%), heterogenous patients,

mutliple technologies

� Most of the literature is single center, � Most of the literature is single center,

retrospective, small # pts

� Few multicenter studies, small #s

� No randomized data for PCCS

� Consensus opinion from experts

Postcardiotomy Shock Definition

� Non standardized:

� Inability to wean from CPB, or

� Marginal hemodynamics in OR, or � Marginal hemodynamics in OR, or

� Dvlpmt of poor hemodynamics in early postop period

� CI < 2 l/min/m2, SBP < 90 mmHg, high filling

pressures and MVO2 < 60 despite adequate Hgb and

pharmacologic support

Postcardiotomy Situations

� Low EF CABG/MV

� Low EF MV

� Low EF CABG/poor targets� Low EF CABG/poor targets

� CABG post acute MI/CS

� RHF after transplant or LVAD

� CABG/post infarct VSD

� CABG/post infarct MR

Goals of Postcardiotomy Assist

� Unload injured ventricle(s)

� Wean toxic level of pressors

� Maintain end-organ perfusion/function� Maintain end-organ perfusion/function

� Allow cytokines to be metabolized

� Allow replenishment of ATP stores

� Allow myocardium to declare recoverability

PCCS: The Typical Story=.

� Difficult operation, failure to wean

� Rest on CPB:

� Optimize pacing, Hct, ABG

� Check TEE for new WMAs, residual valve leaks

� Check graft flows

1-2 hrs

Addtl � Check graft flows

� Escalation of inotropes / pressors

� Reattempt CPB wean

� IABP=you fail again=.

Addtl

CPB !

NOW you consider mechanical support=.coagulopathy,

oliguria, transfusions, hypoxia, pulm HTN, RHF=..

Intra Aortic Balloon Pump = VAD

AdvantagesAdvantagesAfterload ReductionAfterload Reduction

Enhances Coronary PerfusionEnhances Coronary Perfusion

Easily InsertedEasily Inserted

Easily RemovedEasily RemovedEasily RemovedEasily Removed

CheapCheap

DisadvantagesDisadvantages

Limited UnloadingLimited Unloading

≤ 10% Power Increase≤ 10% Power Increase

? Benefit in Non? Benefit in Non--Ischemic SyndromesIschemic Syndromes

IABP Mortality in PCCSIABP Mortality in PCCS

30

35

40

45

50

% Mortality

0

5

10

15

20

25

30

THI SLU Methodist Duke Wash. U

% Mortality

IABP MortalityIABP MortalityWhy so high ?

�� IABP requires stressed heart to continue to IABP requires stressed heart to continue to

expend energyexpend energy

�� The afterload reducing effect < increased The afterload reducing effect < increased �� The afterload reducing effect < increased The afterload reducing effect < increased

myocardial Omyocardial O22 demands of inotropic supportdemands of inotropic support

�� Because IABP benefit is limited, profoundly Because IABP benefit is limited, profoundly

insulted heart may be unable to maintain endinsulted heart may be unable to maintain end--

organ perfusionorgan perfusion

Probability of Death: Postoperative Inotropic Probability of Death: Postoperative Inotropic

SupportSupport

Allegheny University Hospital, Hahnemann DivisionAllegheny University Hospital, Hahnemann Division

100%100%

90%90%

80%80%

70%70%

Probability of death (%)

Probability of death (%)

70%70%

60%60%

50%50%

40%40%

30%30%

20%20%

10%10%

0%0%

No doseNo dose Low doseLow dose Moderate doseModerate dose One high doseOne high dose Two high doseTwo high dose Three or more Three or more

high dosehigh dose

Probability of death (%)

Probability of death (%)

Samuels LE. J Card Surg 1999;14:288-93

Hemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic CriteriaHemodynamic + Pharmacologic Criteria

Hemodynamic:

�BP < 90mmHg (systolic)

�CVP > 15mmHg (mean)

�PAP > 40mmHg (systolic)

�CI < 2.0 L/min/m2�CI < 2.0 L/min/m2

Pharmacologic:

�Epinephrine > 10 mcg/min

�Dopamine > 10 mcg/kg/min

�Dobutamine > 10 mcg/kg/min

�Milrinone > 0.50 mcg/kg/min

Samuels LE. J Card Surg 1999;14:288-93

ABIOMEDABIOMEDBenefit of Early ImplantationBenefit of Early Implantation

30

35

40

0

5

10

15

20

25

30

< 24 Hrs > 24 Hrs

% Weaned

What’s On the Shelf?

Mechanical Options

� Centrifugal Flow Pumps (Biopump, CAPIOX,

Sarns)

� Routine use for CPB

� Short term support

� May be used for ECMO

� Blade, impellers or cones provide momentum creating

high flow at low pressures

� Single moving part, disposable, cheap

� No data supporting superiority of design

Centrifugal Flow Pumps

Mechanical Options

� Extracorporeal Pumps:

� AB5000

� Pulsatile, paracorporeal, portable, pneumatic

� More complex (grafts to Ao, PA)

� Expensive� Expensive

� Versatile

Registry Data (STS)

Most Recent Data

� Survey of all cardiac centers in UK (67)� Survey of all cardiac centers in UK (67)

� 10/07 - 10/08: 28,000 pts, 66 pts underwent VAD for PCCS

� Outcomes

41% d/c home (recovered)

42.5% died on support

16.5% died after successful wean

� Drastic improvement from prior decade (75% mortality)

Mechanical Options

� “New” Technologies

� Percutaneous extracorporeal

� TandemHeart� TandemHeart

� Third Generation Continuous Flow pump

� Centrimag

� Microaxial Flow pump

� Impella system

TandemHeart

� Most versatile system

� Centrifugal pump

� Transseptal LA cannula

PercutaneousPump

� Transseptal LA cannula

� Works with any cannula

� Expensive

� “Purse-string” placement

� Easy for IH transfer

BiVAD ± ECMOController

CentriMag

� Versatile system

� Mag-Lev

� Less hemolysis

� Works with any cannula

Pump

� Works with any cannula

� Expensive

� “Purse-string” placement

� Easy for IH transfer

Console

IMPELLA

� TEE guided transaortic placement

� Through graft sewn to aorta

� No AV injury or AI

� Expensive

� Quick to place

� No RV support; AI, mech valve C/I

� 16 pts with PCCS, 6 hospitals

� 1 high dose or 2 mod dose pressors ± IABP� 1 high dose or 2 mod dose pressors ± IABP

� Mean flow 4 lts/min

� Mean support 3.7 days

� 94% 30d survival

Mechanical Options

� ECMO� Resurgence for all shock etiologies due to cost, mini-, ease of deployment

� Not a “system” but a modality of support� Not a “system” but a modality of support

� Familiarity

� Miniaturized circuits

� Less forgiving with anticoagulation than newer systems

� Doable with all previous systems except Impella, AB5000

� Good for transfer

NO!

PCCS Strategy

� In high risk situations, place femoral line preop

� Insert IABP prior to weaning high risk cases

� Wean CPB (2 Ino/pr); If CI < 2 l/min/m2, filling

pressures are high, and MVO2 less than 60% pressures are high, and MVO2 less than 60%

(with adequate Hct), institute mechanical support

� Do NOT leave OR struggling with hemodynamics

What to Insert: LVAD vs BiVAD

�� Once left heart support in place, observe RV for few Once left heart support in place, observe RV for few

mins:mins:

�� CVPCVP

�� TR (TEE)TR (TEE)

�� LVAD fillingLVAD filling�� LVAD fillingLVAD filling

�� Use pulmonary vasodilators (mil, dob, iNO)Use pulmonary vasodilators (mil, dob, iNO)

�� RV function should improve with LV unloadRV function should improve with LV unload

�� In general, if CVP >16 on inotropic support, place RVADIn general, if CVP >16 on inotropic support, place RVAD

�� When in doubt, BiVAD: RAWhen in doubt, BiVAD: RA--PA, LA/LVPA, LA/LV--AoAo

�� Use ultrafiltration aggressivelyUse ultrafiltration aggressively

�� Reexplore for bleeding earlyReexplore for bleeding early

In ICUF.In ICUF.

�� Have explicit anticoagulation protocolsHave explicit anticoagulation protocols

�� Heart & endHeart & end--organs must have recovered before organs must have recovered before considering weanconsidering wean

�� Reach out to VAD/Txp program early (hub and Reach out to VAD/Txp program early (hub and spoke)spoke)

Not a Good Transfer !!

InterInter--Hospital TransferHospital Transfer

�� Neurologically intactNeurologically intact

�� Not hemorrhaging, on heparinNot hemorrhaging, on heparin

�� Preferably, closed chestPreferably, closed chest�� Preferably, closed chestPreferably, closed chest

�� Not anuricNot anuric

�� Not septicNot septic

�� Transplant/LVAD considerationsTransplant/LVAD considerations

�� Insured or insurableInsured or insurable

Keys to SuccessKeys to Success

�� No device superiority No device superiority -- get comfortable with get comfortable with one systemone system

�� Insert early !!Insert early !!

�� Survival approaches 50% with insertion within 60 Survival approaches 50% with insertion within 60 minutes of first attempt to weanminutes of first attempt to wean

�� Early insertion minimizes complications of Early insertion minimizes complications of prolonged CPBprolonged CPB

�� Consider biventricular supportConsider biventricular support

�� Right heart failure can be swift and fatal Right heart failure can be swift and fatal -- when in when in doubt, support the right heartdoubt, support the right heart

Conclusions

� Recent registry data suggests improvements in PCCS morbidity & mortality

� Likely result of:� Likely result of:

� Earlier institution of support

� Better technology

� Improved ICU care

� Establishment of hub-spoke relationships