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Cardiogenic Shock - In the Era of Advanced Short Term Mechanical Circulatory Support


Michael M. Koerner, MD, PhD
Michael.koerner@integrisok.com

Aly El-Banayosy, MD
Aly.elbanayosy@integrisok.com
INTEGRIS Baptist Medical Center
Oklahoma City, OK, USA



If not treated in a sufficient and timely manner cardiogenic shock (CS) is known to have still a high morbidity and mortality instead of improvements in the therapy eg of acute myocardial infarction (MI) and CS [1].

In 1967 Killip classified the severity of derangement after myocardial infarction into four groups: no heart failure, heart failure, severe heart failure with frank pulmonary edema, and cardiogenic shock (CS): signs including hypotension with a systolic blood pressure (BP) 90 mmHg or less, evidence of peripheral vasoconstriction: oliguria, cyanosis, diaphoresis, and heart failure - often with pulmonary edema [2].

The Shock Trail confirmed CS complicating acute MI by clinical and hemodynamic criteria which have been used since then. Clinical: hypotension (systolic BP <90 mmHg for at least 30 minutes or the need for supportive measures to maintain a systolic BP of >90 mmHg) and end-organ hypoperfusion (cool extremities or a urine output of <30 ml per hour, and a heart rate of ≥ 60 beats per minute - paced rhythm included). Hemodynamic criteria: cardiac index (CI) of no more than 2.2 l/min/m2 of body-surface area and a pulmonary-capillary wedge pressure (PcW) of at least 15 mmHg. Thrombolitic therapy and intraaortic balloon counterpulsation were recommended [3].

Over time new aspects have been added into the assessment of CS: change of mental status, presence and degree of lactic acidosis, systemic inflammatory response syndrome (IL-6, TNF-a, NO)[4,5,6,7].

Acute myocardial ischemia is only one of many reasons that a patient may end up with a profound CS refractory to conventional therapy (PCSref). PCSref can have many etiologies presenting as low- or high-cardiac output syndrome compromising macro- and microcirculation with severe reversible or irreversible multi organ failure and finally causing a patient's death [5,8,9].

Our therapeutic tool box should provide the right tool ready for immediate use in our proactive attempt to break the vicious cycle to reestablish a sufficient circulation with tissue perfusion and oxygenation. In PCSref time is tissue especially brain tissue.

So which device should be at the top of possible recommendations if time is a crucial component for successful immediate effective circulatory support in true cardiogenic shock like PCSref to safe a patient's life and organ function, to gain circulatory stability and time for detailed diagnostic and specific therapies like coronary revascularization? Such a device should be easy to be initiated when and where ever needed (inhospital and in out-of-hospital scenarios) in patients with PCSref without the risk to lose time and tissue by moving these patients to the cath lab or operating room from one hospital to another or the Critical Care Unit, emergency room or even the scene in the field). Compared to other percutaneous inducible devices the veno-arterial extra corporeal membrane oxygenation (VA-ECMO) seems to be the device of choice in patients with PCSref - where minutes count - because tissue (brain) is the major concern [10,11,12].

VA-ECMO seems to be the quickest applicable and most effective tool to restore full circulatory support with 4 to 5 l/min and to provide sufficient tissue oxygenation in patients with PCSref. In those patients VA-ECMO serves as a bridge-to-decision and bridge-to-treatment device. Reported data mostly from utilized older technologies and less advanced critical care settings reflecting real life usage not generated by randomized trials [13].

Any delay to reestablish a sufficient circulation eg due to an additional transport from place A to B will add higher risk to the patient's odds. A door-to-ECMO implantation time <30 minutes significantly improves the 30-day outcome in patients with out-of-hospital cardiac arrest [14,15].

The use of nondurable mechanical support, including the use of percutaneous and extracorporeal ventricular assist devices has recently been recommended as Class IIA in the 2013 ACCF/AHA Guideline for the Management of Heart Failure [16]. The definition of cardiogenic shock has been modified in the 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement together with a statement that in cases of biventricular failure VA-ECMO is the mechanical circulatory support device of choice for patients in cardiogenic shock and impaired oxygenation [17].

Nevertheless way to go: current CS classifications and definitions, especially for PCSref do not classify sufficiently the different aspects and possible therapeutic consequences in regard to "which device when" related to: underlying etiology of the PCSref with expected or observed cytokine release, immune response, metabolic derangements instead of one, two or more inotropic substances, the degree of mitochondrial and/or neuro hormonal involvement, and reversibility of end-organ dysfunction: brain, lungs, kidneys, liver, etc. ■

Disclosure Statement: Dr. Michael M. Koerner has no conflicts of interest to disclose. Dr. Aly El-Banayosy reports receiving speaker fees from Thoratec, Inc., Pleasanton, CA, USA.


References:

  1. Jeger RV, Radovanovic D, Hunziker PR, et al. Ten-year trends in the incidence and treatment of cardiogenic shock. Ann Intern Med. 2008 Nov 4;149(9):618-26.
  2. Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. Am J Cardiol. 1967 Oct;20(4):457-64.
  3. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Engl J Med. 1999 Aug 26;341(9):625-34.
  4. Hollenberg SM, Kavinsky CJ, Parrillo JE. Cardiogenic shock. Ann Intern Med. 1999 Jul 6;131(1):47-59.
  5. Hochman JS, Buller CE, Sleeper LA, et al. Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? J Am Coll Cardiol. 2000 Sep;36(3 Suppl A):1063-70.
  6. Hochman JS. Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm. Circulation. 2003 Jun 24;107(24):2998-3002.
  7. Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. 2008 Feb 5;117(5):686-97.
  8. Koerner MM, Jahanyar J. Assist devices for circulatory support in therapy-refractory acute heart failure. Curr Opin Cardiol. 2008 Jul;23(4):399-406.
  9. Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014 Dec;40(12):1795-815.
  10. Arlt M, Philipp A, Voelkel S, et al. Out-of-hospital extracorporeal life support for cardiac arrest-A case report. Resuscitation. 2011 Sep;82(9):1243-5.
  11. Lebreton G, Pozzi M, Luyt CE, et al. Out-of-hospital extra-corporeal life support implantation during refractory cardiac arrest in a half-marathon runner. Resuscitation. 2011 Sep;82(9):1239-42.
  12. Nusbaum DM, Bassett ST, Gregoric ID, et al. A case of survival after cardiac arrest and 3½ hours of resuscitation. Tex Heart Inst J. 2014 Apr 1;41(2):222-6.
  13. Gray BW, Haft JW, Hirsch JC, et al. Extracorporeal life support: experience with 2,000 patients. ASAIO J. 2015 Jan-Feb;61(1):2-7.
  14. Leick J, Liebetrau C, Szardien S, et al. Door-to-implantation time of extracorporeal life support systems predicts mortality in patients with out-of-hospital cardiac arrest. Clin Res Cardiol. 2013 Sep;102(9):661-9.
  15. Blumenstein J, Leick J, Liebetrau C, et al. Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis. Eur Heart J Acute Cardiovasc Care. 2015 Oct 26. pii: 2048872615612454. [Epub ahead of print]
  16. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. JACC 2013 Oct 15;62(16):e147-239.
  17. Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. JACC 2015 May 19;65(19).e7-26.



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