Lecture presented by Dr Alia Abdel Fattah at the Egyptian African Critical care Summit held at Cairo, Egypt

1. Alia Abd El-Fattah
Professor of Critical Care Medicine,
Cairo University

2. Cardiogenic Shock: Know your enemy:
Definition:
 SBP < 90 mmHg or a value 30 mmHg below basal
levels for > 30 minutes or catecholamines required to
maintain systolic BP > 90 mmHg.
 Clinical signs of pulmonary congestion or PCWP > 15
mmHg.
 Signs of impaired organ perfusion e.g. oliguria, serum
lactate > 2 mmol/L.
 Cardiac index < 2.2 L/min/m2.
 Arteriovenous O2 difference > 5.5 ml/dl.

3. • “Medical” cardiogenic shock
– AMI, end-stage DCM, myocarditis,drug overdose,
Tako-Tsubo…
– Refractory to conventional treatments
• Including IABP?
– Before evolution towards end-stage multiple organ
failure
• Cardiac arrest
• Post cardiotomy
– Failure to wean from CPB

4. • Parameters to evaluate:
– Etiology/Time course of the disease
– Treatments administered
• Rapid increase in inotropes
– Clinical status, in particular neurological status:
• Is it futile to insert a device?
• Other clinical signs associated with rapid deterioration of
cardiac function:
– Nausea, abdominal pain, Alteration of consciousness, skin
mottling
– Tachycardia, rhythm disturbances
– Ionic disturbances, Acidosis
– Hepatic / Renal failure
• Doppler-Echocardiography +++
– LVEF <20%
– Signs of low cardiac output, Ao VTI <7-8cm

5. • 4 types of indications:
– « Bridge to recovery »
– « Bridge to bridge »
– « Bridge to transplantation »
– « Destination therapy »
• But now… In the acute setting…
– Bridge to whatever seems reasonable
– Including “withdrawal” after a few days
• If refractory MOF…

6. • Short-term devices
– Impella
– Tandem Heart
– ECMO/ECLS+++
• LVADs (HMateII, HWare,TAH)
– Not for acute cardiogenic shock
INTERMACS

7.  Non tolerance to inotropic support or vasopressors.
 Majority had PCI & on clopidogril (?? Bleeding).
 May be failed thrombolysis (↑↑ risk of bleeding).
 Usually on mechanical ventilation.
 Delayed referral to mechanical support.
 Usually multi-organ dysfunction.
 Sometimes post-cardiopulmonary arrest.

8.  Intra-aortic balloon pump (IABP).
 Percutaneous ventricular assist devices (PVAD)
e.g. Tandom Heart & Impella.
 Extra-corporeal membrane oxygenator (ECMO).
 Surgically implanted VADs.

9. Mechanism of action:
 Diastolic balloon inflation  increasing
coronary blood flow.
 Systolic balloon deflation resulting in
acute decrease in the afterload thus
facilitating left ventricular ejection.

10. Immediately after AV closure
↑↑ Coronary
perfusion
pressure
↑↑ O2 supply
(coronary &
peripheral)
↑↑ baroreceptor
response

11. Just prior to systole & remains deflated during systole
 Afterload ↑ assisted peak
systolic pressure
↑ ejection
fraction &
cardiac output
Creates potential space in the aorta reducing aortic
volume & pressure resulting in

14. 2010
2012

16. Contra-indications:
 Significant aortic regurgitation.
 Aortic dissection.
 Abdominal aortic aneurysm.
 Uncontrolled bleeding diathesis.
 Uncontrolled septicemia.
 Severe bilateral peripheral vascular disease
uncorrectable by peripheral angioplasty or
cross-femoral surgery.
 Bilateral femoral-popliteal bypass grafts.

17. 1) Limb ischemia:
 The most common vascular complication.
 Management:
• Removal of the IABP.
• Vascular surgery review if ischemia persists
after catheter removal.
Complications:
A) Vascular complications:
IABP Counterpulsation:
2) Aortic dissection.
3) Visceral ischemia.
4) Peripheral thrombotic embolization.
5) Local false aneurysm & AV fistula formation.

18. 1) Misplacement or migration of the balloon (may
lead to occlusion of renal or subclavian arteries
or perforation of aortic arch).
2) Balloon perforation or rupture gas embolism.
3) Anaemia & thrombocytopenia
B) Balloon related complications:
C) Miscellaneous e.g. infection.
Complications:

20.  Centrifugal pump
 Membrane oxygenator
 Controller
 Cannulas
 Tubing

21. NEJM, 1972
Bramson
ECMO
machine

23. In the context of acute
refractory cardiac failure

24. • Allegheny Hospital, Pittsburgh.
• 82 patients who received ECMO (91-97).
o 55 post-cardiotomy.
o 27 in the cath lab.
o 4 cardiac graft failure.
o 6 after cardiac arrest.
• Patients discharged alive: 36%.
o 56%, 96%, 50% and 0%, respectively.

25. • Ann Arbor, Michigan
• 33 patients with ECMO (96-00)
– 19 for ischemic cardiomyopahy,
– 10 for dilated cardiomyopathy,
– 4 post-cardiotomy
– Among them, 24/33 in cardiac arrest at the time
of ECMO initiation
• 10 patients Bridged to a LVAD
• Survivors: 12/33 (36%)
– 7/24 (29%) of the cardiac arrest patients

26. Long term survivors: 28%

27. • 57 cardiac arrest patients, CPR >10 min
• Weaning rate: 66.7%,
• Survival rate: 31.6%.
– Multiple-organ failure major reason for mortality,
despite successful weaning

28. VA-ECMO is now the
first line device…
In the context of acute
refractory cardiac failure

29. Extracorporeal Membrane
Oxygenation: ECMO/ECLS
• ECMO = ExtraCorporeal Membrane Oxygenation:
– Centrifugal Pump + Oxygenator: Heart-Lung support
• Peripheral vascular access:
– Femoral site (cannulas), Seldinger technique, limited cut-down
• Advantages:
– Easy and rapid implantation if peripheral ECMO
• No sterno/cardiotomy, local anesthesia, Emergency
situations
– Provides high and stable output flow
– Simultaneous cardiac and pulmonary assistance: ECMO
– Bridge to: Recovery, Bridge, Transplantation, Withdrawal
– “Low cost” (2 - 40 times cheaper / other devices)

30. The ECMO circuit:
Centrifugal pump
• Electrical
• Centrifugal pump
– 0->4000 RPM
• Can deliver flows up
to 8 L/min
• Very reliable
– Up to 21 days

31. The ECMO circuit:
Membrane Oxygenator
• Hollow fiber membrane
oxygenator
• Polymethylpentene
• Heparin-coated
• High performance
– CO2 elimination
– Blood oxygenation
– Low pressure drop
• Long duration 15-21 d

32. The ECMO circuit:
Central Unit Controller
Flow alarms

33. The ECMO circuit:
Cannulas
• Percutaneous insertion of the
Cannulas (Seldinger)
– Drainage Cannula:
• Femoral Vein
• Long cannula: up to 60 cm
– Return Cannula:
• Oxygenated blood
• Femoral artery
• Shorter cannula: 20-25 cm
• Cannulas Diameter+++
– 22 – 30 Fr for drainage
– 15 – 23 Fr for return

34. Poiseuille’s Law…
• Flow function of the 4th
power of cannula diameter
• Maximize drainage
cannula diameter
– 25-30 Fr
• To decrease pump speed,
pressure and blood trauma

35. The ECMO circuit:
Tubing
• Fully heparin-
coated tubing
• Minimize length
to lower pressure
drop

36. Peripheral cannulation

37. Results of ECMO…
In the context of acute
refractory cardiac failure

38. ECMO program at La Pitié, Paris
0
50
100
150
200
250
300
350
400
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Total
Post CPB
Medical
Portable ECMO
Program

39. 42%
36%

40. Independent predictors of ICU death

44. Left ventricular assist device
INTERMACS (Interagency Registry for Mechanically
Assisted Circulatory Support) stages for classifying
patients with advanced heart failure

45. Tandem Heart pVAD

46. Tandem Heart pVAD
After transseptal puncture a venous inflow cannula
is inserted into the left atrium
Oxygenated blood is drawn from there and returned via
a centrifugal pump and via an arterial cannula
in the femoral artery

47. Tandem Heart pVAD

48. Miniature Intraaortic pump: Impella®

49. Miniature Intraaortic pump: Impella®
The Impella LP2.5 device, a catheter-based miniaturized
rotary blood pump, inserted via a 13-F sheath in the
femoral artery and placed retrogradely through the aortic
valve
The microaxial pump continuously aspirates blood from
the left ventricle and expels it to the ascending aorta with
a maximal flow of 2.5 l/min

50. Impella 5.0

55.  Despite advances in coronary revascularization
& pharmacological treatment, cardiogenic shock
remains a clinical challenge with high mortality
rates.
 Conservative management with inotropes &
vasopressors is associated with serious
limitations including arrhythmias, increased
myocardial O2 consumption and inadequate
circulatory support.
Conclusion

56.  Mechanical circulatory assist systems commonly
used in cardiogenic shock are IABP, venoarterial
ECMO, tandem heart & the Impella.
 Over the past years, clinical studies &
experience demonstrated hemodynamic
improvement & elevation of perfusion pressure
with mechanical support devices.
Conclusion