Mechanical Circulatory Support in Cardiogenic Shock What every - - PowerPoint PPT Presentation

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Mechanical Circulatory Support in Cardiogenic Shock What every - - PowerPoint PPT Presentation

May 23, 2023 230 likes •951 views

Mechanical Circulatory Support in Cardiogenic Shock What every cardiologist needs to know The Surgeon's view ACCA Masterclass 2017 R Trimlett (London, UK) Mechanical Circulatory Support in Cardiogenic Shock What every cardiologist needs

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Mechanical Circulatory Support in Cardiogenic Shock – What every cardiologist needs to know The Surgeon's view ACCA Masterclass 2017

R Trimlett (London, UK)

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Mechanical Circulatory Support in Cardiogenic Shock – What every cardiologist needs to know The Surgeon's view

ACCA Masterclass 2017

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ACCA Masterclass 2017

Potential for Cardiac Support

TOTAL DIED Cath Lab 25,011 1,317 Cardiac Surgery 36,134 990 Intensive Care 238,248 59,562 Accident & Emergency 18,142,311 20,358 Ambulance OOH Arrests 60,000 57,800 Overall UK Mortality 501,424

10000 20000 30000 40000 50000 60000 ITU OOH Arrest A&E Cath lab Cardiac Surgery

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81 Centres providing at least a working-hours Service. 22 performing less than 400 cases per year.

Catheter Labs

Mortality

  • 25,011 Cases

performed

  • 1,317 died
  • 5.3% mortality
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= 1,083 Catheter Labs – OOHA followed by PCI

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IABP – SHOCK II Trial

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IABP – SHOCK II Trial

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IMPELLA DEVICE

Per-cutaneous / Surgical 2.5L / 5L+ Already anticoagulated. May cause Haemolysis.

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ACCA Masterclass 2017

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Compact CardioHelp VV / VA Portable Device

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External Artificial Heart and Lungs

Uses of VA-ECMO

  • Cardiogenic shock
  • Large myocardial infarction (MI)
  • Assistance with CPR using (E-CPR)
  • Post-cardiotomy shock
  • Bridge to more definitive treatment,
  • Bridge to left ventricular assist device (LVAD)
  • Bridge to decision
  • Cardiomyopathic process
  • Fulminant myocarditis
  • Sepsis-associated cardiomyopathy
  • Pulmonary hypertension
  • Pulmonary embolism with right heart failure
  • Class IV/stage D heart failure
  • Post heart transplantation
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CONSIDERATIONS FOR V-A ECMO CANNULATION

  • Time / Urgency
  • Facilities / Location
  • Anatomical Considerations / Physical Size
  • Previous or planned Surgery / Vascular Access
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CONSIDERATIONS FOR V-A ECMO CANNULATION ARTERIAL ACCESS Single Cannula or Multiple Cannulae Femoral Subclavian Aorta Left Ventricle Carotid

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BODY SURFACE AREA – RULE OF NINES

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PRESSURE OF TIME – TWO QUICKEST STRATEGIES (I)

1. FEMORAL CANNULATION Ultrasound Bilateral approach Percutaneous vs. Open Sterile Field Small Cannulae

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PRESSURE OF TIME – TWO QUICKEST STRATEGIES (II)

  • 2. EMERGENCY STERNOTOMY

You will need a saw. If you have a saw, this is very quick Bleeding Sterility Transport

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PRESSURE OF TIME – TWO QUICKEST STRATEGIES (II)

Sternotomy and ‘Clam shell’ incisions both give good emergency access to Heart and Great Vessels. Clam shell can be done Without a saw. Need two retractors for Best access.

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FEMORAL CANNULATION

X-Ray Guided Approach 0.035” J-wire provided (soft) Amplatz Super Stiff if prev. femoral op. Dilate properly and incise skin Wire can loop down opposite leg Wire can enter Hepatic or renal veins

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FEMORAL VENOUS CANNULATION

CANNULA CHOICE Size Multi-stage Dual Drainage / Ascites Cannula Positioning

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FEMORAL ARTERIAL CANNULATION

CANNULA CHOICE Size Distal Perfusion Side arm vent Wire re-inforced

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ALTERNATIVE FEMORAL ARTERIAL CANNULATION

Division of Inguinal Ligament 10mm Side Graft to External Iliac A. No Cannula Used No Distal Perfusion Issues Simple Decannulation

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ALTERNATIVE FEMORAL ARTERIAL CANNULATION

Conventional with Cannulae Surgical Side Graft 10mm Gelseal

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Technique for Cannulation

10mm Graft 3/8” – 3/8” connector 3/8” = 9.56325mm

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CONSIDERATIONS FOR V-A ECMO CANNULATION – FACILITIES

Accident and Emergency Resus. Hybrid Theatre Suite

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ALTERNATIVE FEMORAL ARTERIAL CANNULATION

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STANDARD CANNULATION SITES IN OPEN CHEST

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OPEN-CHEST SITUATIONS

In an Emergency pipes can be held in place. Minimizes retrograde Aortic flow.

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OPEN-CHEST SITUATIONS

Often, in complex Aortic cases, the whole Aortic is replaced by a woven Dacron tube. Haemostasis is a major challenge. Kinking of grafts is an issue.

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Aortic Pulse Amplification

As mean pressure falls along the aorta, the pressure wave is delayed and the pulse amplitude raised.

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Aortic Compliance

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THE IMPORTANCE OF LOW SHEAR STRESSES

Haemolysis ? CVA Lower Pump RPM Less ‘Jet Wash’ of Aorta

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AVOIDING FLOW-LIMITING CANNULAE WITH GELSEAL GRAFTS

No need to remove when weaning off ECMO Close with Stapler and leave a small stump.

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VA-ECMO IN THE PRESENCE OF AORTIC REGURGITATION

Relative Contraindication Ignore. Balloon Pump. LV Vent. Change Valve (AVR). TAVI. Impella Device.

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IMPELLA DEVICE

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Rapid Expansion in Cardiac ECMO (UK)

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913 Patients, short term mortality 62% 347 Patients, 6-month mortality 24% 264 Patients, 1-year mortality 17% 219 Patients alive at 1 year = 76% mortality

A Systematic Research and Meta-analysis

patients with a diagnosis of ACS treated with extracorporeal circulatory support

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Journal of Cardiac Failure Vol. 20 No. 8S August 2014, Sandeep M. Jani et al.

Acute Cardiac Diagnoses. Post-cardiotomy. Acute Decompensation of Chronic Heart Failure. “Other”

ACS

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3 Months 3 years, 1 month

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