Shock in STEMI Intra-aortic Balloon Pump

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1 Shock in STEMI Intra-aortic Balloon Pump Ioannis Iakovou, MD, PhD Onassis Cardiac Surgery Center Athens, Greece

2 Cardiogenic shock 5-10% of pts after a heart attack pts in Europe/year In the last years the mortality rate was reduced mainly by early reopening of the infarct-related artery Still extremely high, approx. 30 days

3 PREDICTION OF CARDIOGENIC SHOCK IN THE CARDIAC CATHETERISATION LABORATORY Poor coronary reperfusion (TIMI Grade <3) Left main coronary occlusion Left ventricular ejection fraction <25% Age >75 years All with 2 of the 4 risk factors died. Garcia-Alverez A et al. Am j Cardiol 2009; 103:

4 OUTLOOK FOR SURVIVORS OF CARDIOGENIC SHOCK GUSTO: 88% of those discharged from hospital are alive at one year SHOCK: 3 and 6 year survival 79% and 62% Around 50% of patients remain free from heart failure symptoms.

5 The Damaging Effects of High Dose Inotropes Elevated stroke work and wall tension. Increased myocardial oxygen consumption. Depletion of energy reserves. Endocardial necrosis & impaired diastolic function. Overall negative effect on myocardial recovery.

IABP history History: 1962 Animal studies Moulopoulos et al, Am Heart J 1962;63:669-675 1968 clinical description in shock Kantrowitz et al, JAMA 1968;203:135-140 1973 Hemodynamic effects

6 IABP history History: 1962 Animal studies Moulopoulos et al, Am Heart J 1962;63: clinical description in shock Kantrowitz et al, JAMA 1968;203: Hemodynamic effects in shock, Mortality unchanged Scheidt et al, NEJM 1973;288: > 40 years > 1 Million patients treated, low complication rate, Benchmark registry Ferguson et al, JACC 2001;38:

7 IABP - why use it? Increase coronary perfusion pressure Increase myocardial oxygen supply without increasing demand Decrease afterload But increase in cardiac output is only L/min

8 IABP in Myocardial Infarction and Cardiogenic Shock Improves diastolic flow velocities after angioplasty Allows for additional intervention to be done more safely

9 Indications for IABP Cardiogenic shock Refractory angina despite maximal medical management Cardiac failure after a cardiac surgical procedure Perioperative treatment of complications due to myocardial infarction Failed PCI Mitral regurgitation As a bridge to cardiac transplantation

10 Contraindications to IABP Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thromboembolism

11 Complications Limb ischemia Thrombosis Emboli Bleeding and insertion site Groin hematomas Aortic perforation and/or dissection Renal failure and bowel ischemia Neurologic complications including paraplegia Heparin induced thrombocytopenia Infection

PAMI-II trial High risk patients were randomized to 36 to 48 h of IABP (n = 211) or traditional care (n = 226) a prophylactic IABP strategy after primary PTCA in hemodynamically stable high risk

12 PAMI-II trial High risk patients were randomized to 36 to 48 h of IABP (n = 211) or traditional care (n = 226) a prophylactic IABP strategy after primary PTCA in hemodynamically stable high risk patients with AMI does not decrease the rates of infarct-related artery reocclusion or reinfarction (p=ns for both), promote myocardial recovery or improve overall clinical outcome Stone et al JACC 1997

13 CRISP-AMI 340 pts with ST elevation MI within 6 hours of the onset of pain Among patients with acute anterior STEMI without shock, IABC plus primary PCI compared with PCI alone did not result in reduced infarct size. Patel et al JAMA 2011

15 7 RCT, 1000 patients No difference in Death, LVEF

16 IABP Use (%) IABP-Use in Cardiogenic Shock ALKK GUSTO I 22 GUSTO III Euro Heart Survey Worcester-Registry NRMI-2 31 NRMI SHOCK-Registry 51 SHOCK-Trial 86 Anderson et al. JACC 1997;30: Hasdai et al. Eur Heart J 1999;20: Goldberg et al. NEJM 1999;340: Zeymer et al. ESC 2009, Abstract Barron et al. Am Heart J 2001;141: Sanborn et al. JACC 2000; 36: Hochman et al. NEJM 1999;341: Zeymer et al. Eur Heart J 2004;25:

17 IABP prior to PCI vs. IABP after PCI

18 Rapid Reperfusion. Would you go the same speed on these two Cases?

19 N Patients Stopped slow recruitment Underpowered Stopped Slow recruitment Surrogate endpoint Stopped due to missing effect Patient Inclusion in Cardiogenic Shock-Studies SHOCK TRIUMPH SMASH PRAGUE - 7 TACTICS IABP- SHOCK I IABP- SHOCK II

21 IABP-shock II study 600 pts randomized to conventional optimal Rx vs. IABP Theile et al ESC 2012

22 30 Day Mortality: Good to be YOUNG

23 12 mo data good if <50 yo!

Guidelines IABP in STEMI complicated by cardiogenic shock Antman et al. Circulation. 2004;110:82-292 O Gara et al.

24 Guidelines IABP in STEMI complicated by cardiogenic shock Antman et al. Circulation. 2004;110: O Gara et al. Circulation. 2013;127:e362-e425 Van de Werf et al. Eur Heart J. 2008;29: Steg et al. Eur Heart J. 2012;33:

25 What do we think we know? IABP in pts with anterior MI but no shock did not reduce infarct size (CRISP-AMI) Guidelines in both US and Europe: recently Class I to Class IIA and IIB Some: IABP in shock patients may help doctors more than patients After looking at data. should anyone get an IABP?

26 Potential treatment algorithm for patients with CS complicating AMI (asterisks denote supported by randomized controlled trials). Thiele H et al. Eur Heart J 2010;31:

27 Recommendations on how to approach shock If a pt has a SBP of mm Hg the aim is to increase BP over the next couple of days while keeping them out of shock; use IABP Do not use IABP in all high risk pts; but consider in the following situations: Severe HF Bridge to surgery Impeding CS Mild CS

28 Conclusions For more severe cases of CS (SBP approx 40,50,60, 70 mmhg) or pts requiring high doses of inotropes or vasopressors we (may) have the option of percutaneous LVAD (Tandemheart or Impella) which provide superior hemodynamic support compared to IABP Until now, we cannot recommend to replace IABP by percutaneous LVAD as first-choice approach in the mechanical management of cardiogenic shock Routine use of IABP in AMI is not evidence based Studies with pre-pci deployment of IABP are needed

29 Thank You!

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