prise en charge du choc cardiogénique post-infarctus- ci < 2.2 l/min/m2 (by echocardiography...
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Priseenchargeduchoccardiogéniquepost-infarctus
Bordeaux–05.02.2019
DrC.Delmas
USIC-CHUToulouseRangueil
PhysiopathologyofCS
UsualCSphysiopathology
• Systolicdysfunction
VanDiepen.Setal,AHACSRecommandations,Circulation2017
• Diastolicdysfunction
• SIRS
ArjolaVP.EurJHeartFailure2018
CSphysiopathology:anevolvingconcept
• Lowcardiacoutput• Pulmonary,renalandliver
congestion• Inflammation/vasoplegia
Organmalfunctionbymalperfusionandcongestion
DifferentclinicalpresentationofCS
VanDiepen.Setal,AHACSRecommandations,Circulation2017
Limitsofusualdefinition
Definition/Diagnosis/Monitoring
CSdiagnosis=classicCSdefinition
VanDiepen.S,CirculationSept2017
UsualdefinitionaremainlyaboutischemicCSandleftventricularfailureCS
Maymissedpre-Shockanddelayedtreatment/supports
CSconcept:evolutionandprogression
Bellumkonda.Letal,AmJCardiol2018
1-Lowcardiacoutputcriteria -SBP<90mmHgorneedvasopressors/inotropstomaintainSBP>90mmHg
-CI<2.2L/min/m2(byechocardiographyand/orinvasivehemodynamicevaluationwithrightheartcatheterization)
2-Rightand/orleftoverloadsignscriteria -Clinical(dyspnea,ralesandcrepitations,jugularvenousdistensionand/orabdomino-jugulartest,edema,…) -Biology(Nt-proBNP>900pg/mland/orBNP>400pg/ml) -Radiology(overloadsignsonchestrayand/orchesttomodensitometry)
-Echocardiography(E/A>2ifLVEF<45%orE/Ea>13ifLVEFwasnormal;orsPAP>35mmHg,and/orEdecelerationtime<150msand/orAp-Am>30msand/orE/Vp≥2,5)
-Invasivehemodynamicevaluationwithrightheartcatheterization(PCWP>15mmHgand/ormPAP>25mmHg)
3-Organmalperfusioncriteria -Clinical(oliguria<0.5ml/kg/h,confusion,cold/clammyskinandextremities,and/ormarbling) -Biology(lactate>2mmol/L,metabolicacidosis,liverinsufficiencyand/orrenalfailure)
Tobeconsideredasacardiogenicshock,patientmustfulfillatleastonecriterionofeachofthe3
components:lowcardiacoutput+leftand/orrightoverload+sign(s)oforganmalperfusion
Asimpleandeasydefinition=FRENSHOCK
Nodifferenceintermsofearlyoutcomesbetweenpatientswithorwithouthypotension
FRENSHOCK772patientsin49centersFrance6months2016 Patientswith(ESC-HF=1),orwithout(ESC-HF=0)hypotension
Allwithlowcardiacoutput,overloadsignsandorganmalperfusion
Delmas.Cetal,JESFC2019
Price.Setal,NatureReviewinCardiology2017
ReynoldsHR.Circ2008
Frenshock
Cardshock
IABPShock2
PlaceofTTE:heartsystolicfunction
evaluation
ArjolaVP.EurJHeartFailure2018
AdaptedbyG.Leurent
Ibanez.Betal,EurHeartJ2017
Limitsandinsufficiency
ofLVEFevaluation!
PlaceofTTE:heartdiastolicfunction
evaluation
ArjolaVP.EurJHeartFailure2018
17%
Lancellotti.Petal,EurJCardiovascImaging2017
Sensibility75%/Specificity74%PPV39%/NPV93%
Placeofinvasivehemodynamicevaluation?
Ibanez.Betal,EurHeartJ2017
Cecconi.Metal,IntCareMed2014
v
v
v
• Notsystematic?• IncaseofRVdysfunction• Incaseofmixedshock
• Incaseoftreatmentfailure
• Managementmonitoring
Mebazaa.Aetal,IntCareMed2018
EpidemiologyanddescriptionofischemicCS
IschemicCS=themainetiology!
• IschemicCS:• Mainetiology(36%inFRENSHOCKregistry)
ShahMetal.ClinResCardiol2017
• OthersCS:Morefrequent• Dilatedcardiopathy.terminal
HF.obstructivecardiopathy.myocarditis.intoxication.valvulopathy.PE.takotsubo.sepsis.…
Delmas.Cetal,inreviewing2019
IschemicCSincidence
↗prevalenceinICU:• 4.4%en1997-2000• 7.7%en2009-2012
Puymirat.Eetal,DatasCubRéa,EJHF2016
Goldbergetal,Circulation2009
Incidence≈stablesince20years
– 5to8%STEMI– 2.5%N-STEMI
=60-70000cas/yearinEurope Thiele.Hetal.,EHJ2010
CCmorefrequentincaseofSTEMI
DeLucaLetal,EJHF2015 28217patientswithACSand526withischemic-CS
X1.5to2
CSmorefrequentinwomen
Puymirat.Eetal,ArchCardiovascDiseases2017
10000patientswithACS(FASTMI1995-2000-2005-2010
X1.5to2
CSismorefrequentwithage
AissaouiNetal,EurJHeartFail2016
P=0.023 P=0.019
P=0.012
10000patientswithACS(FASTMI1995-2000-20005-2010
CS:2temporalpresentation
AwadHHetal,AmHeartJ2012
Ischemic
AllCS
- 24%CCàl’admission- 62%aucoursdes241èresh- 14%aucoursdel’hospitalisationaprès24h
HarjolaVPetal,EHFJ2015
22,3%àl’admission
GRACE CARDSHOCK
CSprognosis
EvolutionoftheischemicCSprognosis
Kunadianetal,JACCCardiovascInterv2014
Raban.V.Jaegeretal,AnnInternMed2008
Aclinicalchallengewithhighmortalityrates
MoresevereprognosisincaseofischemicCS?
HarjolaVPetal,EHFJ2015
• CardSHOCK• Multicentricprospectiveregistry(9europeancenters)
• 219patients=ACS177(rouge)et42NonACS(bleu)
IschemicCSprognosisprediction:IABPShock2score
• Easycriteria=incathlab• Recentcohorts:IABPshockstudy+validationbyIABPregistryandCardShock
Poss.Jetal,JACC2017
TherapeuticmanagementinischemicCS
-Revascularization-Cardio-vasoactiveagents
Highandearlymortality:activemanagement+++
• Highmortalityduringthefirst48h
• Prognosisseemsgoodafter
Kunadianetal,JACCCardiovascIntervention2014
Aissaouietal,CritCareMed2014
Placeofearlydiagnosis+
stratification+treatement
>40%in-hospitalmortality
2.InotropsDobutamine
1.Reperfusion
3.VasopressorsNoradrénaline
ESC 2014 = Classe IB ESC 2016 = Classe IB ESC 2017 = Classe IB
ESC 2017 = Classe IIbC ESC 2016 = Classe IIaC SRLF = strong agreement
CS:Physiopathologyandtherapeuticsapproaches
DelmasCetal,Réanimation2017
ESC 2017 = Classe IIbC ESC 2016 = Classe IIaB SRLF 2015 = strong agreement
Centralplaceofrevascularization++++
AissaouiNetal,EHJ2012
Bangaloreetal,AmJMedecine2015
Ibanez.Betal,
2017ESC
Guidelines,Eur
HeartJ2017
Invasivestrategy=coro+/-revascularization
Bangaloreetal,AmJMedecine2015
IschemicCS:invasivemanagement
strategy
KolteD,AmJCardiol2016
STEMI
N-STEMI
Extentofatherosclerosisinpatientswithcardiogenicshock
Hochman,JSetal.NEJM1999Baumgartetal.,1993
HeushBritishJournalofPharmacology2008
Immediatecompleterevascularization?
ThieleHetal,NEJM2017
• CULPRITSHOCK
• Multicentriquerandomiséeprospectiveeuropéenne(706patients)
DeathorRRT
Differentclinicalpresentations=differenttherapeuticapproaches!!
VanDiepen.Setal,AHACSRecommandations,Circulation2017
§ Fluidchallenge?§ Inotrops?
§ Diuretics?§ Inotrops?§ Vasopressors?
§ Diuretics?§ Inotrops?§ Vasopressors?
WhataboutchronicHFtreatment?
Mebazaa et al, EHJHF 2015 Farmakis.D et al, Int J Card 2015
PonikowskiPetal,ESCHFguidelines,EHJ2016
Cardiogenicshock=stopusual
chronicHFtreatment
1. Norepinephrineshouldbeusedtorestoreperfusionpressureduringcardiogenicshock(strongagreement)
2. Dobutamineshouldbeusedtotreatlowcardiacoutputincardiogenicshock(strongagreement)
3. Phosphodiesteraseinhibitorsorlevosimendanshouldnotbeusedfirstline(strongagreement)
4. CSrefractorytocatecholaminescanbetreatedbyperfusionofphosphodiesteraseinhibitorsorlevosimendan
5. Thereisapharmacodynamicrationalefortheuseoflevosimendaninpatientson
chronicbeta-blockertreatment
Levyetal,AnnalsofIntensiveCare(2015)
Norepinephrinefirst!
Nad=égalementuneffetinotrope+
Beurton.Aetal,Shock2014
Effetsvasculairesα>actionβ1
DonotuseEpinephrineinCS
Leopold.Vetal,IntensiveCareMed2018
• Métaanalysede2583patients• 12cohortes+3étudesrandomisées
Mortalitéx3
9Frenchcentersbetween2011-2016ACSCSrevascularized+Swan-Ganz
Levy.Betal,JAmCollCardiol2018
Whatperfusiontargets?
• Améliorationperfusiond’organes
• Améliorationperfusionmyocarde
• AugmentationdelaMVO2etIschémie
• AugmentationpostchargeVG
• SurchargecalciqueetArrythmies
Ø Cliniques:marbrure,conscience,diurèse+++Ø Lactate,biohépatiqueetrénaleØ SVO2>65-70%
Ø NadpourPAM>65(voir70mmHg?)Ø InotropespourIC≥2,2-2,5L/Min/m2
QSP
Commentadapterlesamines?
Monitoring++++
VanDiepen.Setal,AHACSRecommandations,Circulation2017
• Tenterrégulièrementlesevragechezlespatientsstabilisés
• Savoirimplémentersiinsuffisant
SamuelsLEetal,JCardSurg.1999
Highmortalitydespiteoptmalmedicalmanagement:placeforcirculatory
support?
MortalityRiskwithInotropes/
VasopressorsN=3462
Conventionaltreatmentlimits(1)
Conventionaltreatmentlimits(2)
Thiele.Hetal.,EurheartJ2015
Placefor(cardio)-circulatorysupport?
Supportcirculatoire
(perfusiond’organe)
Décharge
ventriculairePerfusioncoronaire
+ +
PAM PTDVG PAM-PTDVG
KapurNKetal,Eurointervention2016
HCS-PMA-PP01224-027rA
Determinantsofthehemodynamicsupport
Objectifs:Mettrelecœuraurepospourfavoriserlarécupération
EtEviteroucorrigerladéfaillancemultiviscérale
Whentothinkabout(cardio-)circulatorysupport?
Yoshiocaetal,CircJ2012
PlaceforINTERMACSclassification
CardiogenicShock
Bridge to recovery
Bridge to transplantation
Bridge to bridge
Assistance
DiscussionbeforeMCSimplantation:shockTeam+++++++Moyenshumains,matériels,financiers…Questionéthique
Death Bridge to decision
Forwhichpatient’sproject?
CentralplaceforTTEevaluation:LVandRVfunction,mechanicalcomplication,valvedysfunction,…
VitarelliA,HeartFailRev.2010
Which
thresholds?Ibanez.Betal,EurHeartJ2017
• Anavailableandknownsupport• Asupportadaptedateachclinicalsituation
Thieleetal,EHJ2015
WhattypeofsupportinacuteCS?
1970 19902000 2004-2005 2015
IABPplaceinischemicCS?
30days
12months
Thiele.Hetal,NEJM2012
Thiele.Hetal,Lancet2013
Nodifférencevs
medical
treatment!!
IABP-SHOCK II
Axillaire
Fémoral*
Mini sterno
IMPELLA:3devices
• Assistancemono-ventriculairegauche• Pompeaxialerotative(20-50000trs/min)• PlacéeàtraverslaVao• 2typesdepompes:
• Abordpercutané
• Impella2.5(12Fr;5j)• ImpellaCPou3.5(14Fr;5j)
• AbordChirurgical
• Impella5.0(21Fr;10j)=tubeendacron
HemodynamicandclinicaleffectsofImpella
BasirMetal,AmJCardiol2017
SaurenLD,Artiforgans2007;MeynsBJACC2003;RemmelinkMCatheterCardiovascInterv2007;AgelRA,JNuclCardiol2009;
LamKClinResCardiol2009
Impella=acuteLVassistdevice
• RealLVunloading//Nooxygenationanddecarboxylation• GradualLV-Aopressuregradientdecoupling=Impellasupport
Uriel.N,JACC2018/Burkhoff.Detal,JACC2015
ClassIIb
CIbanezetal,EHJ2017
Ponikowskyetal,EHJ2016
WhichsupportinCSpatients:Impella2.5,CPor5.0?
Impella5.0(surgical)orImpella
CP(percutaneous)>>2.5
EngstromAEetal.,CritCareMed2011
O’Neill.WWetal,AmJCardiol2018
Thiele.HetalEHJ2017
Randomizeddatas?:ClinicaleffectsofMCSvsIABP
IMPRESSstudy:gapsandlimitsVeryseverepatients:
• 100vs83%priorCA• 100%ETIandMV• 100%vs92%underinotrops• Traumaticlesion=21%vs8%• Lactates7.5vs8.9mmol/l• pH7.14vs7.17
Nonoptimalmanagement
• 21vs13%beforePCI• Timeundersupport49vs48h
Crossover:• 4.2vs12.5%
Conclusion:ForpostCACSduringACS,ImpellaCPisnotbetterthan
IABP
Ouweneel.DMetal,JACC2016
ProspectivestudiestoevaluatetheefficacyofImpellainischemiccardiogenicshock
LackofrandomizeddatasinCSpatients!
DelmasCetal,ACVD2017
O’Neill.WWetal,AmJCardiol2018
USdata:Experienceroleandlearningcurve
• Real-lifepracticeinUS• 15259CSpatients• Age63.5(+/-12.3)• Male73%
§ Impella2.5(33%)–CP(61%)–5,0(5,2%)§ Impellapre-PCI48%§ Durationofsupport3,78+/-4,8
USdata:whentoimplant?
BeforePCIincaseofischemicCS
ONeill.WW,JIntervCardiol2014
BasirMetal,AmJCardiol2017
• cVADregistry=287patientswithischemicCS
• Layingtime=17min
USdata:whentoimplant?
Assoonaspossible
BasirMetal,AmJCardiol2017
3groups(<1.25h,1.25–4.25h,>4.25h)
Correlationbetweenmortalityandnumberofinotrops
Beforeinotropsincaseof
ischemicCS??
Inhospital
survival
Inhospital
survival
O’Neill.WWetal,AmJCardiol2018
• Real-lifepracticeinUS• 15259patients• Age63,5(+/-12,3)• Male73%
• Impella2,5(33%)–CP(61%)–5,0(5,2%)
• Impellapre-PCI48%
• Durationofsupport3,78+/-4,8
USdata:whentoimplant?
Flaherty.MPetal,JACC2017
But…..
• 237patientsEUROSHOCKregistrymatchedwith237patientsfromIABPShock2study
Schrage.Betal,Circulation2018
And:Significantcostgenerated…
• Netincreaseinspendingwithincreasingtheiruse
• Noformalmortalitygaindemonstratedtodate
Reyentovich.Aetal,Nature
Review2016
Shah.Aetal,JInvasiveCardiol2015
RepaymentfilesbeinganalyzedinFrance...
Uriel.N,JACC2018
ConceptofLVunloading Objective:1. ProvideasufficientflowtolimitMOFand
death=savethepatient2. Reducereperfusioninjuryinordertolimit
myocardialinfarctsizeandlimittheprogressiontoHF=savetheheart
JACCHF
2015 JACC2018
VA-ECMO=Circulatorysupport
• ECMO=circulatoryandrespiratorysupport
• ECMO≠cardiacsupport
• NoLVunloading=LVnotatrest
Burkhoff.Detal,JACC2015ClassIIbC
IbanezPetal,EHJ2017;Ponikowskyetal,EHJ2016
Pavasini.Retal,CritCareMed2017
Observational16studies/739patients8to138patients/study
VA-ECMO:resultsinmiscelaneousCS
OuweneelDMetal,IntCareMed2016
• Frequentseriesandregistries• Norandomizeddatatodate(ANCHORtoujoursenattente…)
MainissuesonVA-ECMOsupport
LVunloadingpromotingrecovery(LV
wallstress,strokeworkandmyocardialoxygenconsumption)
Savetheheart
§ ECMOweaning§ PreventHF
FlowdeliverypromotingorganperfusionandMOF
correction
Savethepatient
§ Stabilizethepatient
IssuescouldbeoppositeunderECMOsupportinCS=>placeofLVunloading?
WHY?LVoverloadisassociatedwithaworseprognosis
• LVD++(n=9)=clinical• LVD+(n=27)=subclinical
LVD• LVD-(n=85)=nosignsof
LVD
Truby.LKetalASAIOJ2017
CorstiaanA.denUiletal,EurJHeartFail2017
• Lactateatimplantation8,4• AMI-CS20%,ADCHF14%,Acute
nonMICS25%,postcardiotomy17%,PE16%,…
132ECMO:34LV;29RVet69BiV
HOW?:WhattypeofLVunloading?
Meani.Petal,EurJHeartFail2017
Vallabhajosyula.S,CircCardiovascularInterv2018
• 22studies=4653patients• Noeffectonshorttermmortality
forthewholecohort• Significantlowermortalityfor
AMICS(RR0.56(0.46-0.67);p<0.001)
• Frequentcomplications+++:transfusion(15-89%),limbischemia(10-37%),…
AMI-CS
• 157ECMO=34ECMO+Impellaand123ECMOalonethenpropensityscorematching
• 64%withpriorCPR;54%STEMI;lactates>9Pappalardo.Fetal,EJHF2017
Patel.SMetal,ASAIOJ2019
Better30-daysand1-yearsurvival
Rapiddeclinein
inotropsuse
Samecomplications
SurgicalLVventing
CanuleapicaleVGparthoracotomiegauchesousETO
Canulesous-clavièreintraVGtrans-aortiquesousscopie
• Canuleveines-pulmonairesparthoracotomiedroiteousternotomie
• Canulesdansl’AP• …
Circuitveineuxdel’ECMO
Balloonatrialseptostomy:fewdatasavailable
• Right-leftshuntbyinteratrialseptumopening
• Complications?/PersistenceofaremoteIAC?
Baruteau.AEetal,EurHeartJACC2018
Bellumkonda.Letal,AmJCardiol2018
1. InitialseverityofCS• MOF
• RVfunction
• Respiratorystatus
3. Localexperiencesandcapacities(vascular
and/orcardiothoracic
surgery?)
Thieleetal,EHJ2015
2. Availabledevice
AcuteMCS:VA-ECMOvsImpelladevice?
Adaptationofcaretothespecificsituation
Notanisolatedbutaglobalstrategy
Montpellier
Mourad.Metal,ASAIO2017
Whatrecommendationsfor
(cardio)-circulatorysupportinCS?
Desniveauxderecommandationsdefaibleniveaumaisquiseprécisent…
DelmasC,Réanimation2017
CSmanagementalgorithm:Protocols+++
Mebazaa.Aetal,IntCareMed2018
Timetotherapy++
+
Earlydiagnosis
and
management
Managementina
specializedteam
MCSifnecessary
Butaslowevolutionofpractices…
ShahMetal,ClinResCardiol2017
• Cost• Eduction/
Training• Habits
USdatas
Butaslowevolutionofpractices… French
datas
Helleu.Betal,ArchCardiovascDiseases2018
172patientsinamulticentre(19frenchcenters)prospectiveregistryin2015
62%
VariationinMechanicalCirculatorySupportUse
StromCircCardiovascInterv.2019
Shaefi.Setal,JAmHeartAssoc2015
533179hospitalizationsforCSin2675hospitalsbetween2004and2011
Expertscenters?
TchantchaleishviliJAMASurgery2015 RabJAmCollCardiol.2018
Placeofaspecializedmultidisciplinaryteam
CSHeartTeam+++
IntCareMed2018
AllischemicCSpatientsshouldbetransferredinexperts/tertiarycenters??
In-hospitalmortalityofpercutaneouscoronaryintervention-
treatedST-segmentelevationmyocardialinfarctionpatientsby
contact-to-balloontime
Scholz Eur Heart J 2018
But
VanDiepen.Setal,CirculationSept2017
ThefirstclearnationalpositionpaperonMCSinCS
ImplementationofCS
managementorganization
Newapproach:«reducetimetosupport»
Bonello.Letal,ArchCardiovascDiseases2017
Abrams.Detal,IntCareMed2018
• DifferentapproachbetweenACSCSandnonACSCS
• Newandclearposition• EarlierMCS
implantationincaseof
ACSCS=prePCIImpella
CP
• IncaseofrefractoryCS=implementationbyImpella5.0orVA-ECMO
ACSCS
Contexte / comorbidité LVAD ? TRANSPLANTATION ? • Troubles psychiatriques; manque de support social; non compliance Peu probable Peu probable • Maladie artérielle périphérique sévère Peu probable Peu probable • HTAP fixée (RAP>6 UW) Peu probable Peu probable • Dysfonction pulmonaire et/ou hépatique sévère - Défaillance multi-viscérale Peu probable Peu probable • Diabète non équilibré avec retentissement viscéral Peu probable Peu probable • IC « non systolique » – Petit VG Peu probable Possible • Défaillance cardiaque droite sévère Peu probable Possible • Déficit neurologique gênant le maniement du matériel – ATCD d’AVC Peu probable Possible • Haut risque chirurgical pour l'implantation Peu probable Possible • Age > 65 ans Possible Peu probable • Obésité IMC > 35 Cas par cas Peu probable • Sepsis ou infection active non contrôlée Peu probable Cas par cas • Coagulopathie sévère (TIH, thrombopénie, saignement actif) Peu probable Cas par cas • Rein à DFG<40 chronique Au cas par cas Peu probable
Istherealongtermproject?
IspredictingCSoccurencemayimproveoutcomes?
- STEMImanagedbyprimaryPCI- Derivationcohort:6838
patients(ORBI)- Validationcohort:2208
patients(RICO)
→Predictivescoreofin-hospitalCSoccurence
Auffret.Vetal,EurHeartJ2018
Personalizedcare?
Surveillance USIC brève ?
Transfert USIC III? Assistance prophylactique?
CourtesyofG.Leurent
IschemicCardiogenicShock:Conclusion
• Frequent:MainetiologyofCS
• Needarapidandmultiparametricdiagnosis
• Management:• Earlyrevascularization• Fluidmanagment• Inotrops(Dobutamin)and(Vasopressors(Norepinephrin)• (Cardio-)circulatorysupportifnecessary
• LVunloading=EarlyImpellaplacement(?)
• Localandregionalprotocols+++• PlaceofNetworkandCSHeartteam