ST-Elevation Myocardial Infarction

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

• Advanced Angioplasty 2008
• Dan Blackman
• Leeds General Infirmary

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Conflicts of interest

• Advisory Boards
• Cordis
• Boston Scientific
• Medtronic
• Nycomed
• Lilly
• St Jude

• Travel/Sponsorship
• Cordis
• Boston Scientific
• Medtronic
• Abbott
• St Jude

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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 351063
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Survival from mechanical causes
Shock Registry JACC 2000361104 36 1110 GUSTO
1 Circulation 200010127 Holzer R CCI 200461196
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Emergency revascularisation - SHOCK Trial
p0.03
p0.11
85 of survivors NYHA Class I/II at 12 months
Hochman JAMA 2000285190
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Emergency revascularisation in the Elderly-
SHOCK Trial
p0.01
p0.01

• gt75 years ERV vs IMS baseline characteristics
• LVEF 28 vs 36 p0.051
• Anterior MI 63 vs 41 p0.18
• Female 54 vs 31 p0.11

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Elderly - SHOCK other registry data
n44
n233
n61
n74
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Single vessel or Multivessel PCI? - SHOCK Trial

• 81 of PCI patients multivessel disease
• 85 PCI IRA only 23 complete revascularisation

plt0.01
pNS
Shock Trial
Shock Registry
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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
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Is there a role for CABG SHOCK Data
pNS
n47
n81
n276
n109

• SHOCK Trial CABG vs PCI baseline characteristics
• LMS Disease 41 vs 13 p0.051
• 3VD 80 vs 60 p0.18
• Diabetes 49 vs 27 p0.11

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Intra-aortic balloon pump counterpulsation
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IABP in Cardiogenic Shock Primary PCI
Retrospective analysis of 23,180 patients from
NRMI database 7268 treated by IABP
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Timing of IABP in Cardiogenic Shock Primary PCI

• Single centre registry Primary PCI for shock

Brodie AJC 19998418
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Inotropes and Vasopressors

• No meaningful data!
• ACC/AHA Guidelines
• SBP lt70-
• 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

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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

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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

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Tandem Heart Outcome Data
pNS
Improved haemodynamic parameters Increase in
bleeding, limb ischaemia, and sepsis
Thiele EHJ 2005261276. Burkhoff AHJ 2006152e1
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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
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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

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What we should do about STEMI Cardiogenic Shock

• Emergency angiography and revascularisation
  Primary PCI preferably
• All patients lt75 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