Cardiogenic Shock searching for the recent

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Cardiogenic Shocksearching for the recent

• Dr. Yasser Ahmed Salem
• Lecturer of anesthesia
• Ain shams University

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Objectives

• Acute right heart syndrome
• Takotsubo cardiomyopathy
• Pharmacotherapy
• Future of heart transplantation
• Non pharmacologic therapy

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Acute right heart syndrome

• Increase in RV afterload
• RV dilates deterioration of contractility
• Right atrial and RV end-diastolic pressure rise
• Cardiac output fall

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Preload volume entering ventricles
Afterload resistance ventricles must overcome to
circulate blood
Contractility Power of contraction
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Precipitating events

• Acute or acute on top of chronic pulmonary
  embolism
• Deterioration of chronic pulmonary arterial
  hypertension
• ALI, ARDS or sepsis
• Lung resection
• LV failure or LV assist device
• Cardiac surgery
• Heart, lung or liver transplantation

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Right Heart Intolerance
Positive inotropes
CO
RV
LV
45 mmHg
150 mmHg
AFTERLOAD (MEAN PRESSURE)
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Management
Reverse precipitating events
Maintain perfusion pressure
Control contributing factors (acidemia, anemia,
infection, arrhythmia)
RV failure
Optimize fluid volume
Oxygenation and lung protection
Inotropy
Pulmonary vasodilators
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Optimize fluid volume

• Ventricular interdependence
• Cautious fluid administration (bolus and observe
  response)
• Dilated IVC on echo, unlikely to respond
• Consider cautious diuresis
• Massive fluid overload, consider CVVH

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Maintain perfusion pressure

• Norepinephrine, Dopamine, Epinephrine
• AIM
• To treat systemic hypotension (no clear winner)
• To maintain RV coronary perfusion without
  pulmonary vasoconstriction or impaired myocardial
  performance

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Inotropy

• Dobutamine (catechol), milrinone (PDE3I)
• Systemic vasodilators
• dobut tachy
• mil decrease BP, often need pressors
• Mild pulmonary vasodilators
• May be used in combination with more potent
  pulmonary vasodilators (like inhaled NO or PGI2)
  to increase CO and further lower PA pressure
• No clear winner
• Bradford et al, J Cardiovasc Pharmacol 2000
  36146

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Pulmonary vasodilators

• Decrease PVR and impedance to reduce RV afterload
• Increase RV stroke volume and cardiac output
• Avoid systemic hypotension and maintain coronary
  perfusion ( ?PVR/SVR)
• Avoid hypoxemia (from worsened ventilation/perfusi
  on relationships)

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Inhaled prostaglandins

• PGI2 (Prostacyclin)
• Potent vasodilator, decrease platelet aggregation
• Strong evidence for efficacy in Class IV PAH
  (improve functional status and survival)
• Given as continuous IV infusion starting at 2 - 4
  ng/kg/min, increased as tolerated
• Systemic vasodilator, may worsen hypoxemia
• Inhaled form is more specific pulmonary
  vasodilator
• Inhaled ilioprost
• given as separate buffs 25 µ gm every 20 min

De Wet et al, J Thorac Cardiovasc Surg 2004 127
1061
Kramm et al, Eur J Cardiothor Surg, 2005
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Inhaled prostaglandins
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Inhaled NO

• Potent vasodilator - stimulates soluble guanylate
  cyclase in vascular smooth muscle, increase
  intracellular cGMP
• Usually improves O2 - by enhancing blood flow to
  ventilated areas
• Virtually no systemic side effects immediately
  inactivated by hemoglobin (forms methemoglobin)
• Given by titration in concentrations of 5-40 ppm
  (little gain gt 20 ppm)

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limitations

• Withdrawal problems very common (2/3)
• Drop SBP, O2 sats, increase PVR
• ? Related to suppression of endogenous eNOS
• Methemoglobin and NO2 may accumulate
• Very expensive! Up to 3000/day

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Phosphodiesterase 5 inhibitors

• Potent acute pulmonary vasodilators by slowing
  metabolism of cGMP
• Potentiate the effect of iNO or prostacyclin,
  reduce rebound
• Also systemic vasodilators so must be used with
  great caution in hypotensive patients
• prelim evidence suggests more selectivity by
  inhaled route

Ruiz M et al, J Heart Lung Txplant 2006
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Takotsubo cardiomyopathy
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Takotsubo cardiomyopathy
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Takotsubo cardiomyopathy
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Figure 1. Proposed pathophysiology of takotsubo
cardiomyopathy.
Hessel E A , London M J Anesth Analg
2010110674-679
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Objectives

• Acute right heart syndrome
• Takotsubo cardiomyopathy
• Pharmacotherapy
• Future of heart transplantation
• Non pharmacologic therapy

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Pharmacotherapy
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ATP
ß-Adreno- receptor
SR (Ca)
Enzyme
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ATP
SR
Ca
ß-Adreno- receptor
SR (Ca)
Enzyme
Ca
Ca
cAMP
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ATP
SR
Ca
ß-Adreno- receptor
SR (Ca)
Enzyme
Ca
Ca
cAMP
PDE
PDEI
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Clinical Application Clinical Application
      1st Line Agent 2nd Line Agent
Septic Shock Norepinephrine (Levophed) Vasopressin
      Phenylephrine (Neosynephrine) Epinephrine (Adrenalin)
Heart Failure     Dopamine  Milrinone
      Dobutamine  
Cardiogenic Shock     Norepinephrine (Levophed)
      Dobutamine  
Anaphylactic Shock     Epinephrine (Adrenalin) Vasopressin
Neurogenic Shock     Phenylephrine (Neosynephrine)  
Hypotension Anesthesia-induced Anesthesia-induced Phenylephrine (Neosynephrine)  
  Following CABG Following CABG Epinephrine (Adrenalin)  
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Dopexamine

• Newly developed synthetic catecholamine,
  structurally related to dopamine, dobutamine

• Increase splanchnic(gut, kidney, liver, spleen)
  blood flow ? stimulation of DA1 receptor
• Increase in stroke volume, heart rate
• Decrease in peripheral vascular resistance ? b2
  receptor
• Significant increase UO
• Inhibitory action in the neuronal catecholamine
  uptake mechanism ? positive inotropic action

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Fenoldopam

• HTN
• significant and sustained reduction in blood
  pressure ( average decrease in diastolic BP
  20mmHg)
• increased renal blood flow, urine volume sodium
  excretion, potassium excretion
• CHF
• dose related increase in CO by primarily
  decreasing systemic vascular resistance
• no direct inotropic effect

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Phosphodiesterase inhibitor

• Bypiridine
• -amrinone
• -milrinone
• Imidazole
• -enoximone
• -piroximone

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Phosphodiesterase inhibitor

• Noncatecholamine, nonadrenergic
• Inhibition of type III Phophodiesterase
• ( predominantly in cardiac muscle)
• secondary increase in cyclic adenomonophosphatase
• increase in calcium channel entry into the cell
• positive inotropic action
• Decrese pulmonary vascular resistance
• increase cyclic guanidine monophosphate,
  secondary to incresing NO from endothelium
• B-agonist additive
• improvement of myocardial performance

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Amrinone

• Treatment of patient with CHF
• Perioperative period
• positive inotropic and vasodilator action
  undergoing cardiac surgery
• Augment ventricular performance in vascular
  surgery
• pulmonary HTN, chronic pulmonary obstruction in
  children

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Milrinone

• Second generation phosphodiesterase III inhibitor
• Positive inotropic and vasodilating activities
• 20 times of amrinone
• increase CO without increasing the overall
  myocardial oxygen consumption
• Thrombocytopenia
• active amrinone metabolite n-acetyl amrinone
• no reduction in platelet count

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Enoximone

• Imidazole PDE inhibitor derivative
• CHF awaiting cardiac transplatation, undergoing
  CPB
• Cardiac and vascular profile
• similar to other PDE III inhibitor
• Two potential advantage
• Oral administration
• Low incidence of associated dysrhythmia

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LEVOSIMENDAN
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Dosing

• 6 - 12 µg/kg bolus over 10 min then
• 0.05 0.2 µg/kg/min for 24 h
• Correction on hypovolemia
• Correction of potassium and magnesium
• Tight monitoring of blood pressure for 6 h
• Norepinephrine may be added

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Future of heart transplant
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The problem!!!!!!!
Comparison of 1- and 5-year survival after
hospitalization for heart failure
Obviously irreversible damage !
Dilated Cardiomyopathy
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The problem!!!!!!!

• More deaths from heart failure than from any
  other CV disease
• 5.3 million symptomatic patients estimated 10
  million in 2037
• Incidence About 550,000 new cases/year
• Prevalence is 1 between the ages of 50 and 59,
  progressively increasing to gt10 over age 80

Obviously Big Growing Problem!
American Heart Association. 2008 Heart and Stroke
Statistical Update.
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Heart transplantation

• Heart transplantation remains a viable solution
  for many of these patients
• Shortages in donor supply have limited this
  valuable resource to lt2500 patients per year
• An estimated 10 to 20 of patients die annually
  on the waiting list

SPARITY
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Number Of Heart Transplants Reported By Year -
Worldwide
J Heart Lung Transplant 200726 769-781


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A plan to treat heart failure by transplantation ?
Heart Transplants Performed
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Have to seek for alternative
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Non pharmacologic therapy
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Ventricular containment

• ACORN net
• Myosplint
• Skeletal muscle assist

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Acorn Cardiac Support Device
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Myosplint
Change in radius
R1
R2
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Skeletal Muscle Assist

• Can Skeletal Muscle Mimic Cardiac Muscle ?
• Power Output
• Fatigue Resistance
• Speed of contraction

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Cardiomyoplasty
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Cardiomyoplasty What went wrong?

• Stimulation Protocol
• Fast type converted to slow type
• Failure to show systolic improvement
• 2000 cases worldwide
• Medtronic stopped making stimulator
• Patients felt better
• Minimal survival benefit

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Aortomyoplasty
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The Biomechanical Heart
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Skeletal muscle ventricleGirsch, et alSheep
model
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Skeletal muscle ventricle
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Mechanical assist devices

• Principles
• Direct systolic augmentation of the heart,
• Mechanical pumping to divert blood from the left
  atrium/ventricle directly into the aorta with
  sufficient force to maintain normal arterial
  pressure,
• Diastolic augmentation

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Mechanical assist devices

• Pulsatile
• Heartmate, Jarvik 7
• Axial
• Bearings
• Jarvik 2000, Heartmate II
• No Bearings
• Heartmate III

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Implantable IABP

• The Kantrowitz CardioVADTM (KCV)
• 60cc pumping chamber
• Percutaneous access device (PAD),
• External controller
• Clinical trials
• 5 men (age 59 to 73)

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Cardiowest artificial heart
It is a pulsatile, pneumatically driven
prosthetic pair of ventricles made of polyurethane
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Cardiowest artificial heart
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Cardiowest artificial heart
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The Akutsu-III total artificial heart
The second TAH implanted in a human.
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REMATCH
Randomized Evaluation of Mechanical Assistance
Therapy for Congestive Heart Failure
Rose EA, Gelijns AC, Moskowitz AJ, et al. N Engl
J Med 20013451435 - 43.

• survival of medically treated and LVAD patients
  at 1 year was 48 versus 26
• and at 2 years was 26 and 8, respectively.
• Recent modifications of technique and
  perioperative care have decreased the high
  LVAD-related morbidity and mortality observed in
  REMATCH

Park SJ, Tector A, Piccioni W, et al. Left
ventricular assist devices as destination
therapy a new look at survival. J Thorac
Cardiovasc Surg 20051299 - 17.
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AbioCor Artificial Heart

• Cost 70-100 Grands

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Transcuteneus energy transfer T.E.T.
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Pump constituents
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Procedure
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Procedure improvement
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Pulse wave in T.A.H.

• Natural pulse has a 50 diastole time, which
  gives heart and blood vessels time to relax
• Natural pulse has a very steep form

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