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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
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
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
Hinweis der Redaktion
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.