Cath-lab Crashes and postcardiotomy Failure

AATS 2014, Adult Cardiac Surgery Symposium
Postcardiotomy Cardiogenic Shock:
Pearls & Pitfalls
Daniel Goldstein MD FACS FACC
Professor & Vice Chair
Dept. Cardiothoracic Surgery
Disclosures
 Thoratec Inc., Medical Advisory Board
 HeartWare Inc., Scientific Advisory Board,
Surgical Proctor
 Terumo, Chair, AEC, DuraHeart BTT Trial
 SunshineHeart Inc, DSMB
 Medtronic Inc, Consultant
 Will NOT discuss unapproved devices
PCCS
• Most vexing problem faced by cardiac
surgeons
• Very poor outcomes (25-50% discharge)
• 0.2-6% of OHS cases (1300 to 41K/yr)
• Limited literature, no randomized trials,
multiple technologies and patient
heterogeneity
Postcardiotomy Shock
Definition
• Non standardized:
• Inability to wean from CPB, or
• Marginal hemodynamics in OR, or
• Dvlpmt of poor hemodynamics in early postop
period
• Hemodynamic Profile
• CI < 2 , SBP < 90, high filling pressures and
MVO2 < 60 despite adequate Hgb and
pharmacologic support
Who Is At Risk?
•
Low EF CABG/MV
•
Low EF MV
•
Low EF CABG/poor targets
•
CABG post acute MI/CS
• LV Dysfunction
• VSD
• Mitral Regurgitaion (MV Rupture)
• Free Rupture
Not Just Pump Failure…
• PCCS results from low cardiac output
• It is also a multiorgan organ dysfunction
syndrome (MODS) characterized by
– peripheral hypoperfusion,
– microcirculatory dysfunction
– proinflammatory cytokine release
• Once MODS established, improving CI
unlikely to improve survival
Goals of Postcardiotomy Assist
 Unload injured ventricle(s)
 Wean toxic level of pressors
 Maintain end-organ perfusion/function
 Allow cytokines to be metabolized
 Allow replenishment of ATP stores
 Allow myocardium to declare recoverability
PCCS: The Typical Story….
 Difficult operation, failure to wean
 Rest on CPB:
 Optimize pacing, Hct, ABG
 Check TEE for new WMAs, residual leaks
 Check graft flows
 Escalation of inotropes / pressors
 Reattempt CPB wean…marginal
 IABP…you fail again….
1-2 hrs
Addtl
CPB !
Epiphany !
• NOW you consider mechanical support:
•
•
•
•
•
•
•
•
Coagulopathy
Oliguria
Acidosis
Transfusions
Hypoxia
Pulm HTN
RHF
….and you are exhausted
PCCS: What Are the
Options ??
• Inotropes and pressors
• IABP
• Advanced mechanical support:
• Impella LD
• ECMO: central vs peripheral
• Extracorporeal uni- or bi-vad
Inotropes & Pressors
• Inotropes (dob,
milr):
Pros:
• Improve CI
• Reduce afterload
Cons:
•
•
•
•
Inc m O2 demand
Tachycardia
Arrhythmogenic
Vasodilation
• Pressors (norepi,epi,
neo, vaso, dopa):
Pros:
• Improve MAP
Cons:
– Constrict splanchnic
and peripheral
circulation
Probability of Death
Postoperative Inotropic Support
Probability of death (%)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
No dose
Low dose
Moderate dose
One high dose
Two high dose
Three or more
high dose
Samuels LE. J Card Surg 1999;14:288-93
Intra Aortic Balloon Pump = VAD
Advantages
Afterload Reduction
Enhances Coronary Perfusion
Decreases LVEDP, Wall Stress
Easily Inserted/Removed
Cheap
Disadvantages
Limited Unloading
≤ 10% Power Increase
Injured Myocardium Still Needs to
Expend Energy
?Benefit in Non-Isch Syndrome
Acute Mechanical Support
What’s On the Shelf?
• Centrifugal pumps (LVAD, RVAD, BiVAD):
– Conventional
– New generation:
• Tandem Heart
• Centrimag
ECMO
• Pulsatile pump (LVAD, RVAD, BiVAD):
– AB5000
• Axial pump (LVAD)
– Impella LD
Centrifugal Pumps
 Biopump, Capiox, Sarns
 Routine use for CPB
 Short term support
 May be used for ECMO
 Blade, impellers or cones provide momentum
creating high flow at low pressures
 Single moving part, disposable, cheap
 No data supporting superiority of design
Percutaneous
TandemHeart
Pump
 Most versatile system
 Centrifugal pump
 Transseptal LA cannula
 Works with any cannula
 Expensive
 Easy for IH transfer
BiVAD ± ECMO
Controller
Thoratec Centrimag
 Magnetically levitated
 Centrifugal pump
 Sternotomy
 Uni- or Bi-VAD
 Any cannula
 Excellent flows
 Anticoagulation
 Extubate, ambulate
 Expensive
IMPELLA (2.5, CP, 5, LD)
 TEE guided transaortic placement
 Through graft sewn to aorta
 No AV injury or AI
 Expensive
 Quick to place
 No RV support; AI, mech valve C/I
AB5000
 Pulsatile
 Paracorporeal
 Uni- or Bi- VAD
 Sternotomy and CPB
 Anticoagulation
 Arterial cannulae sutured to Ao/PA
 Expensive
 Days to weeks
 Extubate, ambulate
ECMO (V-A)
 Resurgence for all shock etiologies:





“Anyone” can do it
Quickest deployment
Improved O2ator technology
Mini-circuit
Well reimbursed
 Not a “system” but a modality of support
 Doable with centrifugal pumps, Tandem,
C-mag
 Good for transfer
ECMO
•
$1,300
Perc or open
≈ $65K + $10K
Pearls I – Getting Ready
 Discuss with anesthesia ino-pressor strategy
for CPB weaning ahead of time
 Inform perfusion to have your preferred
system available in the room from the outset
so no time is wasted
 Place femoral line preop
 Insert IABP prior to weaning high risk cases
(EF ≤ 20)
Pearls II - Simplify
• Get comfortable with ONE system –
ECMO or BIVAD (tandem, c-mag or
impella LD plus RVAD) - that allows for
full control of circulation
Pitfalls I – Don’t Delay
• Don’t go back on bypass to “rest the
heart for 30 minutes” if already on IABP
and 2 high dose pressors and failing
Pearls III – LVAD or BiVAD ??
• Insert LVAD. Wean CPB w Inotrope for RV
• Watch RV function:
– Free wall, TEE (TR)
– Swan: CVP
– LVAD filling w/o LV collapse
• If CVP high, MAP low and/or cannot fill LVAD
(LV collapses), place RVAD
• RA-PA
• In general, low threshold for RVAD
ECMO
Pearls - ECMO
• Open (use CPB Cannulae, consider LV vent
Yd to venous limb) or percutaneous
• Leave IABP in place if already in – provides
pulsatility and helps LV unloading
• REMEMBER – ECMO increases LV afterload
• Close chest and full protamine reversal
Pearls ECMO II
• Need to manage:
–Heart/circulation
–Leg (perc)
–Lungs
Pearls : the Leg !!
Ischemia = fasciotomy = rhabdo = renal failure
bleeding
RRT
No LVAD
Txp
Pearls: Lungs
• 20-25% LV standstill – coupled w high
afterload from ECMO
pulm edema
• Inotrope to improve LV contractility and
reduce PCWP
• IABP
• LV Venting:
– Impella 2.5
– Septostomy
– Thoracotomy/open chest and apical or RSPV LV
vent
LVAD/BIVAD
Cannulation Options
•
Right inflow
– Right atrium with cannula across the tricuspid valve
– Right atrium with cannula tip in body of RA
•
Right outflow
– Direct PA cannula or graft
– Cannulation of the acute margin of the right ventricle with a transpulmonic cannula
•
Left inflow
–
–
–
–
•
Left atrium at or near the right superior pulmonary vein
Left atrial dome behind the root of the aorta
Left atrial appendage (sp)
Left ventricular apex
Left outflow
– Ascending aorta cannula or graft
– Femoral artery
– Axillary artery
Cannula locations
•
Right inflow
– Right atrium with cannula tip in body of RA
•
Right outflow
– Direct PA cannula or graft
•
Left inflow
– Left atrium at or near the right superior pulmonary vein
– Left ventricular apex
•
Left outflow
– Ascending aorta cannula or graft
LA – Ao LVAD
LA – Ao LVAD RA – PA RVAD
Ao and PA
LV Apical
Cannulation
Apical sewing
cuff
Inter-Hospital Transfer
 Neurologically intact
 Hemodynamically stable
 Not hemorrhaging, on heparin
 Chest closed
 Not anuric
 Not septic
 Cannula secured
 Transplant/LVAD considerations
 Insured or insurable
Not a Good Transfer !!
Keys to Success
 PCCS is a mortal condition
 Prepare for high risk cases
 No device superiority - get comfortable
with one system
 Insert early !!
 Consider biventricular support
 Right heart failure can be swift and fatal
- when in doubt, support the right heart
 Contact Hub hospital early
Pearls: In ICU….
 Use ultrafiltration aggressively
 Reexplore for bleeding early
 Have explicit anticoagulation protocols
 Heart & end-organs must have
recovered before considering wean
 Reach out to VAD/Txp program early
(hub and spoke)