mechanical circulatory support in cardiogenic shock ... · genoa 15th-16th november 2019 am leone:...

Genoa 15th-16th November 2019AM Leone: Pathophysiology of Mechanical Circulatory Support

Genoa 16th November 2019

Mechanical Circulatory Support in cardiogenic

shock: pathophysiological approach and

pressure / volume curvesAntonio Maria Leone MD PhD

Department of Cardiovascular and Thoracic SciencesFondazione Policlinico Universitario A. Gemelli IRCCS

Roma


Speaker's name: Antonio Maria Leone

I have the following potential conflicts of interest to report:

Dr. A.M. Leone received speaking honoraria from Abbott Vascular, Medtronic, Bracco Imaging and Abiomed.

Dr. has NO financial relationship with the Harvi App, PV loops LLC, Apple Inc and CDLeycom

Potential conflicts of interest


Metrics for Evaluating Different Methods of Percutaneous Hemodynamic Support

0 25 50 75 100 125 1500

25

50

75

100

125

150

LV Volume (ml)

LV P

ress

ure

(m

mH

g)

A

B

C

DIs

ovo

lum

icco

ntr

acti

on

Ejection

Isovo

lum

icrelaxatio

n

Filling

A. End Diastole – Mitral Valve Closure

B. Aortic Valve Opening

C. End Systole - Aortic Valve Closure

D. Mitral Valve Opening

ESPVR: End Systole PV Relationship (depends from contractility)

Ees: end systolic elastance

V0: Volume axis intercept

EDPVR: End Diastole PV Relationship (depends from diastolic properties)

EDV (EDP): end diastolic volume (pressure)(PRELOAD)

Ea: effective arterial elastance (AFTERLOAD)

EesV0 Ea EDVESV

Ven

tric

ulo

-art

eria

lco

up

ling=

Ea/E

es

Basile Russo Leone Minerva Cardioangiol 2018:66:600-605


Pressure-Volume Area: Measure of Total Mechanical Energy that Correlates with Myocardial Oxygen Consumption

Left Ventricular Volume

Le

ft V

en

tric

ula

r P

res

su

re

SW

Stroke Work (SW):A Measure of Mechanical Energy

PE

Potential Energy (PE):A Measure of Stored Energy

PVA = SW + PE


Normal Heart and Acute Heart Failure

PV Loop of a Normal Heart

PV Loop of an Acute Heart Failure

0 25 50 75 100 125 1500

25

50

75

100

125

150

LV Volume (ml)

LV P

ress

ure

(m

mH

g)

Contractility ↓↓

Native LV SV ↓↓

LVEDP ↑↑

PCWP ↑

Afterload ↑

MVO2 ↑


Effect of Inotropes and Vasopressors on PV loops

Dobutamine Dobutamine + Norepinephrine

Contractility ↑

Native LV SV ↑

LVEDP ↑↓

PCWP ↑↓

Afterload ↓

MVO2 ↑ ↑

Contractility ↑↓

Native LV SV ↑↓

LVEDP ↑

PCWP ↑

Afterload ↑ ↑

MVO2 ↑ ↑

0

25

50

75

100

12

150

LV P

ress

ure

(m

mH

g)

0 25 50 75 100 125 150LV Volume (ml)

0 25 50 75 100 125 150LV Volume (ml)

A B


Effect of different LV supports on PV loops


Effect of IABP on PV loops

LVEDP ↓

LAP ↓

PCWP ↓ ↑

Native LV SV ↑

Afterload ↓

MVO2 ↑↓0 25 50 75 100 125 150

0

25

50

75

100

125

150

LV Volume (ml)

LV P

ress

ure

(m

mH

g)


JAMA 2010, Circulation 2013

Elective high risk PCIIn severe left ventricular dysfunction (EF <30%) and extensive coronary disease

(Jeopardy Score 8/12)

When IABP could be enough ?

In high risk PCI elective IABP insertion is better than its bail-

out use!!!

… but PCI conduction is not affected!!!

(similar technique, similar extent of revascularization …)


Effect of IABP on mortality for CS in Clinical Studies

Thiele et al. N Engl J Med 2012; 367:1287-1296


After 13’ from cath lab arrival

Can IABP be helpful in a such complex scenario?

After 16’ from cath lab arrival

Courtesy from F. Burzotta 2007

- MALE, 52 years

- Anterolateral STEMI (4 hours since symptom’s onset)

- 18/02/2007, 5:10 am

- At cath lab arrival: AP: 90/50 mmHg, HR: 115bpm


After 25’ from cath lab arrival After 30’ from cath lab arrival After 42’ from cath lab arrival

Courtesy from F. Burzotta 2007

Can IABP be helpful in a such complex scenario?


Trans-femoralVenous Cannula In RA

(18-21 F)

Trans-femoral Arterial Cannula In Descending

Aorta (18-22 F)

Centrifugal Pump With Continuous Flow (> 4.5

L/Min) + Oxygenator

The ECMO

Burzotta G. Ital Cardiol 2018:19:5-13


Effect of ECMO on PV loops

LVEDP ↑

LAP ↑

PCWP ↑

Native LV SV ↓

Afterload ↑

MVO2 ↑0 25 50 75 100 125 150

0

25

50

75

100

125

150

LV Volume (ml)

LV P

ress

ure

(m

mH

g)

ECMO 1.5 l/min

ECMO 3.0 l/min

ECMO 4.5 l/min


Effect of ECMO in CS after MI

• Low numbers

• Variable mortality


ECMO in Cardiac Arrest beyond RCTs

67 yrs ladyDiabetes, no previous historyInferior STEMI complicated by Cardiac arrest in ER


Effect of LA to Arterial Circulatory Support on PV loops

LVEDP ↓

LAP ↓

PCWP ↓

Native LV SV ↓

Afterload ↑

MVO2 ↓

0 25 50 75 100 125 1500

25

50

75

100

125

150

LV Volume (ml)

LV P

ress

ure

(m

mH

g)

LA to A 1.5 l/min

LA to A 3.0 l/min

LA to A 4.5 l/min


Effect of LV to Arterial Circulatory Support on PV loops

LVEDP ↓

LAP ↓

PCWP ↓

Native LV SV ↓

Afterload ↑

MVO2 ↓

The ideal MCS!?!

0 25 50 75 100 125 1500

25

50

75

100

125

150

LV Volume (ml)

LV P

ress

ure

(m

mH

g) Impella 2.5 l/min

Impella CP 3.7 l/min


Schrage Circulation 2019;139:1249-1258

Wernly Clin Res Cardiol 2019

Effect of Impella on mortality in RCTs in CS for MI

And So? The Party is Over?


PROTECT-1 Trial Dangas Am J Cardiol. 2014: 113(2):222-8

p=0.042

29% reduction In MACCE

@ 3-months

Impella

Time Post Procedure (day)

MA

CC

E (%

)

100 20 30 40 50 60 70 80 90

10

15

20

25

30

IABP

N=216

N=211

MACCE (3-month) by revascularization extent

35,0%

28,5%

32,5%

15,9%

1 Vessel Treated 2 or 3 Vessels Treated

IABPN=80

ImpellaN=77

IABPN=130

ImpellaN=130

p=0.747 p=0.015

44% reduction In MACCE

@ 3-months

Effect of Impella on MACCE in high risk PCI

MACCE


- 23 yrs old female- Atypical pneumonia complicated by sepsis- V-V ECMO > V-A ECMO- Myocardial unloading with Impella CP: ECPELLA

MYOCARDIAL VENTING by IMPELLA IN V-A ECMO


Effect of ECPELLA PV loops

LVEDP ↓

LAP ↓

PCWP ↑

Native LV SV ↓

Afterload ↓

MVO2 ↓0 25 50 75 100 125 150

0

25

50

75

100

125

150

LV Volume (ml)

LV P

ress

ure

(m

mH

g) ECPELLA

ECMO 4.5 l/min


• PV Loops offers a comprehensive way to assess severity of LV dysfunction and usefulness of different MCSs

• IABP can unload the ventricle but the amount of this effect could be limited. Consequently, It can be ineffective in severe circulatory failure

• ECMO is a life saving MCS in extreme situations. Nevertheless, its effect on circulation is counter-physiologic

• LA to arterial system can effectively unload left system but It lacks of easiness

• LV to Aorta systems unload the LV while providing support being theoretically the ideal MCS

Conclusions


• The real cause for the lack of effectiveness observed in trials is still unclear (complications, duration of assistance, amount of support, severity of disease…)

• The availability of devices that can easily calculate PVL in vivo would be much appreciated

Conclusions


31

• Now you have the Basics!

• We can move on to the most exciting applications of mechanical circulatory support

Thank You!!!!

mechanical circulatory support in cardiogenic shock ... · genoa 15th-16th november 2019 am leone:...

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