cath lab essentials : lv assist devices for hemodynamic...
TRANSCRIPT
![Page 1: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/1.jpg)
Michael A. Gibson, MD Assistant Professor of Medicine University of California, Irvine
Division of Cardiology
Cath Lab Essentials : LV Assist Devices for
Hemodynamic Support
(IABP, Impella, Tandem Heart, ECMO)
![Page 2: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/2.jpg)
Disclosures
I have no financial or other conflicts of interest
to report.
![Page 3: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/3.jpg)
Cardiogenic Shock
Inadequate end organ perfusion due to a reduced
cardiac output despite adequate circulatory volume
AMS; Cold, clammy skin; Oliguria;
Increased serum lactate
1. Cardiac Index (CI)
CI < 1.8 L/min/m2
CI < 2.2 L/min/m2 with inotropic/pressor support
2. PCWP > 15 mmHg or LVEDP >18
3. Systolic Blood Pressure (SBP)
SBP < 90 mmHg for at least 30 mins
SBP > 90 mmHg with inotropic/pressor support
![Page 4: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/4.jpg)
Causes of Cardiogenic Shock
Cardiology Clinics, 2013; 31(4): 567-580,
![Page 5: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/5.jpg)
Physiology of Cardiogenic Shock: A Downward Spiral
Myocardial ischemia
Damaged heart muscle
Cardiac output
[ CO]
Blood pressure [ BP]
CO & BP
Myocardial ischemia
Venous return
15
14
13
12 11
10
9
8
7 4
5
6
1
2
3
Myocardial Infarction
Death
Coronary artery perfusion
NO synthesis
CO
BP SVR
Inflammatory activation (TNF-α, IL-6)
Myocardial perfusion
Vasodilation
[SVR ]
Hemodynamic support
Reperfusion :
PCI or CABG Reducing
inflammatory
response: ?
![Page 6: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/6.jpg)
![Page 7: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/7.jpg)
![Page 8: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/8.jpg)
Emergency revascularisation - SHOCK Trial
47%50%
53%56%
63%66%
0%
10%
20%
30%
40%
50%
60%
70%
30 days (n=302) 6 months (n=301) 12 months (n=299)
Mo
rta
lity
(%
)
ERV
IMS
85% of survivors NYHA Class I/II at 12 months after early revascularization or
initial medical stabilization Hochman JAMA 2000;285:190
p=0.11
p=0.03
![Page 9: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/9.jpg)
New England Journal of Medicine: 2003; 348:2007-18
Heart muscle can recover with support High Potential
of heart muscle recovery, Gain in Ejection Fraction
Low Potential of heart muscle recovery, Loss in Ejection Fraction
9
![Page 10: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/10.jpg)
The primary goals of nondurable MCS
devices are to acutely:
1. Increase vital organ perfusion
2. Augment coronary perfusion
3. Reduce ventricular volume and filling
pressures, thereby reducing wall stress,
stroke work, and myocardial oxygen
consumption
![Page 11: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/11.jpg)
Intra-Aortic Balloon Pump
Introduced in 1968 (Kantrowitz)
First “true percutaneous” support device
Cheapest, most common (20% of all cardiogenic shock cases), CO 0.5L/min
Stabilize pt, but not full support
No outcome benefit
Diastolic pressure
CO/cardiac workload
MAP
LV Wall Tension
PCWP
Oxygen Demand
LV Volume
Coronary Blood Flow
Hemodynamic Effects
![Page 12: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/12.jpg)
Optimal IABP function is determined by four factors: 1. The magnitude of diastolic pressure augmentation
2. The magnitude of reduced systolic pressure
3. The magnitude of volume displacement
4. The timing of balloon inflation and deflation
Curr Cardiol Rep. 2015; 17:40
![Page 13: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/13.jpg)
Nair et al Journal of Invasive Cardiology 2011
![Page 14: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/14.jpg)
IABP-Shock II Trial: Results Primary Study Endpoint: 30-day Mortality
(IABP in Cardiogenic Shock and Primary PCI)
Thiele H et al. NEJM 2012;367:1287
![Page 15: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/15.jpg)
Indications for IABP
High Risk PCI Cardiogenic Shock Refractory Ischemia Left Main 3 Vessel CAD VT/VFib
MR or VSD after MI Severe CHF? Bridge to Transplant Pre-operative stabilization
![Page 16: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/16.jpg)
Contraindication to IABP
Severe Peripheral vascular disease Aortic regurgitation Aortic Dissection PDA HOCM Heparin intolerance Bleeding Diathesis Sepsis
![Page 17: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/17.jpg)
Complications of IABP
Vascular access bleeding/complications Limb ischemia Infection Thrombocytopenia Migration and aortic arch trauma Other non-vascular (CVA, embolization
of cholesterol, balloon rupture)
Air embolism risk (reduced by using
helium gas)
![Page 18: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/18.jpg)
35
Hemodynamic Advantage of Hemodynamic Advantage of
pVADpVAD vs. IABPvs. IABP
►► Directly unload the left Directly unload the left ventricle ventricle
►► Reduce myocardial Reduce myocardial workload and oxygen workload and oxygen consumption consumption
►► Increase cardiac output Increase cardiac output and coronary and endand coronary and end--organ perfusion organ perfusion
pVAD IABP
+++ -
+++ ++
+++ +
![Page 19: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/19.jpg)
Impella
Continuous axial flow
pump
Simple insertion
Increases cardiac
output & unloads LV
LP 2.5 – CO 2.5 L/min
CP 4.0 L/min
14 F percutaneous
LP 5.0
21 F surgical
cutdown; Maximum
5L flow
![Page 20: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/20.jpg)
Impella Insertion
![Page 21: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/21.jpg)
Mimic Heart’s Natural Function
Inflow
(ventricle)
Outflow
(aortic root)
O2 Demand O2 Supply Cardiac Power
Output
EDV, EDP AOP Flow
Principles of Impella Design
Myocardial Protection Systemic Hemodynamic Support
Naidu S S Circulation 2011;123:533-543
![Page 22: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/22.jpg)
• Impella 2.5
• High risk PCI patient
• Demonstrated net
CO increase with
simultaneous
ventricular unloading
7.4 L/min
Native
CO
Impella
(2.4)
6.0 L/min
Systemic Hemodynamic Support CO Increase … Valgimigli et al.,Cath Cardiov Interv (2005)
5.0
M.Valgimigli et al.,Catheterization & Cardiovascular Interventions 65:263–267 (2005)
Total
Cardiac Output
Pump
Off
6.0 L/min
9/21
Pump
On
7.4 L/min
Pump
OffPump
On
18 mmHg
11 mmHg
Pump
OffPump
On
94 mL
76 mL
IMPELLA Unloads Actively the Ventricle, Reduces
Work Loads and Increases Cardiac Output
LV LV
pump
End-Diastolic
LV PressureEnd-Diastolic
Stroke Volume
![Page 23: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/23.jpg)
![Page 24: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/24.jpg)
![Page 25: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/25.jpg)
![Page 26: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/26.jpg)
![Page 27: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/27.jpg)
Complications Hemolysis
May respond to repositioning the device
Persistent hemolysis associated with acute kidney injury
Bleeding
Limb ischemia/vascular injury
Stroke
Contraindications Mural thrombus in the LV
Presence of a mechanical aortic valve
Aortic valve stenosis (AVA ≤ 0.6cm2)
Moderate to severe aortic insufficiency
Severe PAD
VSD
![Page 28: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/28.jpg)
![Page 29: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/29.jpg)
![Page 30: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/30.jpg)
![Page 31: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/31.jpg)
Case
52 year old female lap cholecystectomy
complicated by injury to the common bile duct
and sepsis.
Patient become acutely tachycardic to 160s and
hypoxic.
![Page 32: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/32.jpg)
![Page 33: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/33.jpg)
![Page 34: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/34.jpg)
![Page 35: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/35.jpg)
![Page 36: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/36.jpg)
![Page 37: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/37.jpg)
![Page 38: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/38.jpg)
CO
MAP
PCWP
Hemodynamic Effects
TandemHeart
Left atrial-to-femoral
arterial LVAD
21F venous transseptal
cannula
17F arterial cannula
Maximum flow 4L/min
![Page 39: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/39.jpg)
Transseptal puncture
21 F cannula in LA
![Page 40: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/40.jpg)
Venous cannula arterial return cannula
TandemHeart Cannula
![Page 41: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/41.jpg)
![Page 42: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/42.jpg)
TandemHeart Shock Study
Cardiac Index
0
1.4
1.8
2.2
1.6
2.0
2.4
Card
iac
In
de
x(l
/min
/m2
)
IABP
1.5
1.7
PerVAD
1.7
2.3
Prep=0.4
n=20 n=21
Postp=0.005
IABP PerVAD
Thiele and al. Eur. Heart Journal 2005 Jul;26(13):1276-83
30-day Mortality
0
10
30
50
20
40
60
30
-day
Mo
rta
lity
(%
)
IABP
45%
PerVAD
43%
p=0.8
9/20 9/21
Limb Ischemia
0
10
30
50
20
40
60
Lim
b I
sc
he
mia
(%
)
IABP
0%
PerVAD
33%
p=0.009
0/20 7/21
Transfusion
IABP
40%
PerVAD
90%p=0.002
8/20 19/21
0
40
60
80
50
70
90
Re
qu
ire
d T
ran
sfu
sio
n (
%)
100
![Page 43: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/43.jpg)
![Page 44: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/44.jpg)
![Page 45: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/45.jpg)
![Page 46: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/46.jpg)
Extracorporeal Membrane Oxygenation (ECMO)
![Page 47: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/47.jpg)
Cannulation
Femoral vein cannulated with 21-25Fr catheter tip in the right
atrium.
Femoral artery cannula 17-21 Fr inserted to the taper with the tip
at the common iliac artery or lower aorta.
Distal antegrade perfusion cannula inserted into common
femoral artery to prevent distal limb ischemia. Usual size 5-9 Fr
![Page 48: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/48.jpg)
Peripheral Cannulation
Retrograde peripheral flow
leads to admixing in the arch
If there is respiratory
insufficiency, the heart will
pump poorly oxygenated
blood to the coronaries and
proximal arch vessels while
ECMO supplies oxygenated
blood to the rest of the
body.
![Page 49: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/49.jpg)
Advantages and Disadvantages
Relatively Inexpensive (as compared to Impella/TandemHeart) Double the cost of conventionally
treated patients ($65K)
Favorable lifetime predicted
cost-utility
Minimally invasive (peripheral cannulation)
Bedside deployment
Biventricular support
Pulmonary support
Labor intensive (ACT monitoring,
bedside monitoring, management)
Patient is immobilized
LV distention
High complication risk (57%)
![Page 50: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/50.jpg)
Bridge to Nowhere Absolute
Unrecoverable heart and not a candidate
for transplant or VAD
Presence of severe chronic organ failure
Severe brain injury OR Prolonged CPR
Severe peripheral vascular disease
Severe aortic insufficiency
Relative
Obesity
Malignancy
Contraindication to anticoagulation
Advanced age >75
Compliance (financial, cognitive,
psychiatric, or social limitations)
![Page 51: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/51.jpg)
71 yo M 4h intermittent chest pain, light
headedness, pallor, sweating. Inferior STEMI.
Left Coronary System has mild CAD. RCA is
100%. JVD 12cm. Fluids, Dopamine given. BP
72/55, HR 68bpm. What now? IABP? LVAD?
![Page 52: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/52.jpg)
Percutaneous Biventricular Acute MCS Support Configuration
Kapur et al. Circ. 2017;136:314-326
![Page 53: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/53.jpg)
Mechanical circulatory support for RV failure
Kapur et al. Circ. 2017;136:314-326
![Page 54: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/54.jpg)
Approach to Cardiogenic Shock
Consider IABP in:
Cardiogenic shock (mild)
Moderate to severe cardiogenic shock, on inotropes and
vasopressors:
Consider Impella (CP, 5.0L), TandemHeart, ECMO
Biventricular cardiogenic shock:
Consider ECMO or combined percutaneous
LVAD/RVAD
![Page 55: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/55.jpg)
Optimal Timing
(early, late, futility)
Optimal Support Device
Optimal
Therapy
Optimal
management of
device (avoiding
complications)
Euro Heart J(2015) 36, 1223–1230
![Page 56: Cath Lab Essentials : LV Assist Devices for Hemodynamic ...medicine.uci.edu/cathlab-cme/Presentations-2019/Gibson-LVAssist... · shock cases), CO 0.5L/min Stabilize pt, but not full](https://reader030.vdocuments.site/reader030/viewer/2022040712/5e1726fad8a7ba59265710a2/html5/thumbnails/56.jpg)
Thank You