Navin K. Kapur, MD, FACC, FSCAI, FAHA
Associate Professor, Department of Medicine
Interventional Cardiology & Advanced Heart Failure Programs
Executive Director, The Cardiovascular Center for Research & Innovation
Shock is the New STEMIFuture Directions in Cardiogenic Shock
Relevant Disclosures
Research Funding & Speaker/Consulting Honoraria:
Abiomed, Abbott, Boston Scientific, Maquet, Medtronic, MD Start, Cardiac Assist
Herbert J. Levine
Foundation
Tufts Medical Center
RO1HL139785, RO1H133215
Charlton Award
Tufts Medical Center
Triage and Transfer for STEMI
The Hub and Spoke Model
Triage and Transfer for Cardiogenic Shock
The Hub and Spoke Model
AHA Consensus Statement 2017
ECG = STEMI PAC = SHOCK
Rapid, Available, and High Yield Diagnostic Tools
From Drugs to Devices in STEMI and Shock
Drug Device
Drug Device
Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision making
Kapur et al. Curr Cardiol. 2016
Change 1: Pheno-profiling Cardiogenic Shock
1010 Cases
CP + RP
IABP only
Impella 5.0
Impella 5.0 + RP
Impella CP
Impella RP
No AMCS
Other
VA ECMO
VA ECMO + Impella CP
176, 22%
178, 22%
145, 18%
16, 2%
24, 3%
5, 1%
2, <1%
162, 20%
83, 10%
27, 3%
Impella VA-ECMO 0
20
40
60
80
100
Pulmonary Artery Catheter Pre-AMCSM
ort
ality
(%
)
No
Yes
p<0.001
A B
C D
<9 9-12 13-17 ≥180
20
40
60
Right Atrial Pressure (mmHg)
Mo
rtality
(%
)
*
*
†
†‡
142 120 136 178
*, p<0.05: Compared to RAP <9 mmHg†, p<0.05: Compared to RAP 9-12 mmHg‡, p<0.05: Compared to RAP 13-17 mmHg
<9 9-12 13-17 ≥180
20
40
60
Right Atrial Pressure (mmHg)
Mo
rtality
(%
)
*
*
†
†‡
142 120 136 178
*, p<0.05: Compared to RAP <9 mmHg†, p<0.05: Compared to RAP 9-12 mmHg‡, p<0.05: Compared to RAP 13-17 mmHg
NonCongested
LV RV BIV0
20
40
60
80
100
Mo
rtality
(%
)
103 189 34 246
* †* †
*, p<0.05: Compared to Non-congested†, p<0.05: Compared to LV-dominant
Let the Hemodynamics Guide Your Decision Making
Morine & Kapur et al. Shock Working Group
Courtesy of D. Burkhoff Kapur Lab
Change 2: LV Unloading as a Therapy not Simply an
Adjunctive Intervention for Support
Lija Swain : Kapur Lab 2018
Ingenuity Pathway Analysis
Mitochondrial Dysfunction
Oxidative Phosphorylation
Sirtuin Signaling Pathway
TCA Cell Cycle
Fatty Acid b-oxidation
Beta-adrenergic signaling
Change 2: LV Unloading as a Therapy not Simply an
Adjunctive Intervention for Support
An Integrated View of AMI and Shock Biology
C
Kapur Lab
Ventricular Load Impacts Myocardial Recovery
O’Neill W. JIC 2013
Change 2: LV Unloading as a Therapy not Simply an
Adjunctive Intervention for Support
Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision making
Biventricular Congestion in Shock is
Common and Deadly
NonCongested
LV RV BIV0
20
40
60
80
100
Mo
rtality
(%
)
13/98 32/180 14/32 99/235
* †* †
Cardiogenic Shock Working Group
0 10 20 30 400
20
40
60
80
RAP (mmHg)
PC
WP
(m
mH
g)
Total Congestive Profiles Scatterplot
Non-Survivor
Survivor
14
18
Change 3: Unloading and Decongestion
<9 9-12 13-17 ≥180
10
20
30
40
50
Right Atrial Pressure (mmHg)
Mo
rtality
(%
)
*
*
†
†‡
134 113 130 168
<9 9-12 13-17 ≥180.0
0.5
1.0
1.5
2.0
2.5
Right Atrial Pressure (mmHg)S
eru
m C
reati
nin
e (
mg
/dl)
p<0.001
Right Atrial Pressure is a common denominator for poor outcomes
Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision makingVenous Congestion Drives Mortality and Morbidity
Cardiogenic Shock Working Group
Tufts Cardiogenic Shock Algorithm
Hemodynamically driven decision makingRecognizing the Cardio-Renal Axis in Shock
Patel and Bezerra et al ASAIO 2018
Change 4: Optimizing ECMO Venting Strategies
Superior Outcomes with EcPella vs ECMO
Antegrade Perfusion6Fr Braided Sheath
Impella CP 14Fr Sheath
PA Catheter 8Fr Cordis
17Fr Arterial Cannula25Fr MS Venous Cannula
Antegrade Perfusion6Fr Braided Sheath
High Pressure 3-Way + 2 Male-to-Male
Connectors
Change 5: Increasing Focus on Vascular
Outcomes (Deployment and Removal)
2 x 035 wires through7/14Fr telescoping sheath
RemovingCP & Repo Sheath
Side-arm stylet removedCath Lab – sterile prepAntibiotics on board
Sheaths out. 7Fr buddy dilatorPerclose Number 1 at 10:00 Dry Bed with Perclose 1 Hemostasis with 2 Perclose
devices and 10 minute hold
Change 5: Increasing Focus on Vascular
Outcomes (Deployment and Removal)
From Door to Support to Door to Unload
Percutaneous Left Atrial Decompression Reduces LV
Wall Stress and Reduces Infarct Size
Kapur NK et al Circulation 2013
Introduced a 30 minute delay to reperfusion
after LV Unloading
Kapur NK et al JACC HF 2015
Primary Unloading : Impella Micro-Axial Pump
Reperfusion Unloading Reperfusion Unloading0
5
10
15
20
% S
car
by L
GE
or
An
ato
mic
Path
olo
gy
LGE by CMR Anatomic Pathology
p = 0.03 p = 0.02
Primary Unloading Reduces LV Scar and Preserves Cardiac
Output 30 days after Acute MI
Esposito, Zhang, Qiao and Kapur et al JACC 2018
Heart Attack (no pump)
Heart Attack (+ Pump)
Reperfusion
Alone15 min 30 min Unloading After
ReperfusionUnloading Before
Reperfusion
Unloading First & Delaying Reperfusion
Maximally Reduces Infarct Size (Preclinical)
*
JACC 2018
DTU-Pilot
DTU-Pivotal
Door To Unload: STEMI Safety & Feasibility Trial
Informed Consent
Enrollment and Randomization
Explant Impella CP after a minimum of 3 hours support
INCLUSION CRITERIA• Age 21-80 years• First Myocardial Infarction• Acute STEMI (anterior ST elevation ≥2 mm in ≥2 contiguous or ≥4 mm ST-sum)• Within 1 to 6 hours of symptom onset
Anterior STEMI Referred for Primary PCI
Impella CP Insertion + Activation
LV Unloading, Then Immediate PCI Reperfusion
(U-IR Group)
LV Unloading for 30 minutes,Then Delayed Reperfusion
(U-DR Group)
ENROLLMENT COMPLETED
May 2018
Late Breaking Presentation at
AHA 2018 – Chicago – Nov 2018