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ST-Elevation Myocardial Infarction & Cardiogenic Shock - What Should We Do?

ST-Elevation Myocardial Infarction & Cardiogenic Shock - What Should We Do?. Advanced Angioplasty 2008 Dan Blackman Leeds General Infirmary. Advisory Boards Cordis Boston Scientific Medtronic Nycomed Lilly St Jude. Travel/Sponsorship Cordis Boston Scientific Medtronic Abbott

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ST-Elevation Myocardial Infarction & Cardiogenic Shock - What Should We Do?

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  1. ST-Elevation Myocardial Infarction& Cardiogenic Shock- What Should We Do? Advanced Angioplasty 2008 Dan Blackman Leeds General Infirmary

  2. Advisory Boards Cordis Boston Scientific Medtronic Nycomed Lilly St Jude Travel/Sponsorship Cordis Boston Scientific Medtronic Abbott St Jude Conflicts of interest

  3. Causes of Cardiogenic Shock Tamponade/rupture 1.7% Other 7.5% Isolated RV Shock 3.4% VSD 4.6% Acute Severe MR 8.3% Predominant LV Failure 74.5% Shock Registry JACC 2000 35:1063

  4. Survival from mechanical causes Shock Registry JACC 2000;36:1104 & 36: 1110 GUSTO 1 Circulation 2000;101:27 Holzer R CCI 2004;61:196

  5. Emergency revascularisation - SHOCK Trial p=0.03 p=0.11 85% of survivors NYHA Class I/II at 12 months Hochman JAMA 2000;285:190

  6. Emergency revascularisation in the Elderly- SHOCK Trial p=0.01 p=0.01 • >75 years ERV vs IMS baseline characteristics • LVEF 28% vs 36% p=0.051 • Anterior MI 63% vs 41% p=0.18 • Female 54% vs 31% p=0.11

  7. Elderly - SHOCK & other registry data n=44 n=233 n=61 n=74

  8. Single vessel or Multivessel PCI? - SHOCK Trial • 81% of PCI patients multivessel disease • 85% PCI IRA only; 23% complete revascularisation p<0.01 p=NS Shock Trial Shock Registry

  9. “The panel believes that all accessible vessels should be treated in patients with cardiogenic shock” “Current Recommendations:- 1-2 vessel disease: PCI IRA 3VD: PCI IRA + staged complete revascularisation Early MV PCI may be warranted if shock persists despite IRA PCI”

  10. Is there a role for CABG – SHOCK Data p=NS n=81 n=47 n=276 n=109 • SHOCK Trial CABG vs PCI baseline characteristics • LMS Disease 41% vs 13% p=0.051 • 3VD 80% vs 60% p=0.18 • Diabetes 49% vs 27% p=0.11

  11. Intra-aortic balloon pump counterpulsation

  12. IABP in Cardiogenic Shock Primary PCI Retrospective analysis of 23,180 patients from NRMI database 7268 treated by IABP

  13. Timing of IABP in Cardiogenic Shock Primary PCI • Single centre registry Primary PCI for shock Brodie AJC 1999;84:18

  14. Inotropes and Vasopressors No meaningful data! ACC/AHA Guidelines SBP <70:- Norepinephrine (0.5-30 g/min) Switch to Dopamine (5-15 g/kg/min) once SBP ≥80 SBP 70-100 Dopamine (5-15 g/kg/min) Add dobutamine(2-20 g/kg/min)once SBP ≥90

  15. Percutaneous left ventricular assist devices • Even with revascularisation and IABP support mortality from cardiogenic shock post STEMI remains ≥50% • Recovery of myocardial performance following successful revascularisation may take several days. During this time many patients succumb to low cardiac output • If effective, active cardiac support could be provided while awaiting the beneficial effects of revascularisation, survival rates may be enhanced

  16. Tandem Heart pLVAD • Left atrial-to-femoral arterial LVAD • Low speed centrifugal continuous flow pump • 21F venous transeptal cannula • 17F arterial cannula • Maximum flow 4L/minute • Cost: 7.5K

  17. Tandem Heart Outcome Data p=NS Improved haemodynamic parameters Increase in bleeding, limb ischaemia, and sepsis Thiele EHJ 2005;26:1276. Burkhoff AHJ 2006;152:e1

  18. Impella • Axial flow pump • Much simpler to use • Increases cardiac output & unloads LV • LP 2.5 • 12 F percutaneous approach; Maximum 2.5 L flow • LP 5.0 • 21 F surgical cutdown; Maximum 5L flow • Cost: 3-5K Blood Inlet Blood outlet Motor Pressure Lumen

  19. Impella outcome data • 1 RCT of Impella 2.5 in AMI Cardiogenic Shock • ISAR-SHOCK • 26 patient RCT Impella vs IABP •  Cardiac Index,  MAP (by 10mmHg) vs IABP • Complications ≤ IABP • No difference in mortality

  20. What we should do about STEMI Cardiogenic Shock • Emergency angiography and revascularisation: Primary PCI preferably • All patients <75 years • Selected patients ≥75 years • On-table echo to rule out mechanical defects • Stabilise the patient in the lab before revascularisation • IABP • Pressors if required (Norepinephrine/dopamine) • Anaesthetic support • Consider calling the surgeon for true surgical disease • PCI culprit artery. Other vessels if shock persists • Use abciximab for PCI • Consider percutaneous LVAD if shock persists with IABP + multi-vessel revascularisation

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