Impella

Report
5rd International Prof. Dr. Alireza Yalda Foundation in
Medical Sciences
Mechanical support of the heart in cardiogenic
shock
6-10 October, 2014, Tehran, Iran
Abbas Ferdosi, M.D.
Clinic of Cardiovascular and Thorax Surgery
Bad Rothenfelde, Germany
Abbas Ferdosi M.D.
Oct. 2014
Pathophysiology of cardiogenic shock
Abbas Ferdosi M.D.
Oct. 2014
 Mortality has been decreased since
2003
 < 75 J: 62% >>> 50%
 ≥ 75 J: 35% >>> 30%
 Mortality female> male
Germany / year
 280,000 myocardial infarctions
 40% STEMI
112000
 10% followed by CS
11000
Abbas Ferdosi M.D.
Oct. 2014
Results
Schuechtermann Clinic
Bypass surgery in acute myocardial infarction
(<24h)
1/2004 - 09/2006
n = 321 (30-day mortality was 10%)
Myocardial infarction
Without shock In shock
n
211
110
30 days
mortality
1,4%
27%
Age (years)
67,3 (38-94)
66,5 (33-85)
EF < 30%
14,2%
56,3%
Abbas Ferdosi M.D.
Oct. 2014
Mechanical Option
• Intra Aortic Balloon Pump (IABP)
• Extra Corporeal Membrane Oxygenation (ECMO)
• Impella
Abbas Ferdosi M.D.
Oct. 2014
IABP
An investigation was undertaken to determine whether the blood
supply through narrowed coronary arteries could be improved by
delaying the arterial pressure wave so that it arrives in the
coronary arteries during diastole.
In 1967 it was clinical introduction.
Currently 100.000 implantation per year.
Abbas Ferdosi M.D.
Oct. 2014
Intra-Aortic Balloon Pump (IABP)
functional principle
Intra-Aortic Balloon-counterpulsation
Abbas Ferdosi M.D.
Oct. 2014
IABP functional principle
Abbas Ferdosi M.D.
Oct. 2014
IABP functional principle
Abbas Ferdosi M.D.
Oct. 2014
IABP functional principle
Diastole
 Balloon inflates
 Increased blood flow to coronaries
Systolie
 Balloon deflates
 Afterload is reduced
 Increased forward blood flow
Abbas Ferdosi M.D.
Oct. 2014
Effects of IABP Therapy
Coronary perfusion
Stroke Volume
Ventricular Emptying
Cardiac output
LV Workload
Myocardial oxygen Demand
Abbas Ferdosi M.D.
Oct. 2014
IABP- Indication

Cardiogenic shock

Intractable angina pectoris

Low cardiac output after CABG

Support for diagnostic, percutaneous revascularisations and
interventional procedures

Others…
Abbas Ferdosi M.D.
Oct. 2014
Contraindication

Severe aortic regurgitation

Aortic dissection

Aneurysm of the abdominal or thoracica aorta

Severe calcific aorto- iliac disease or peripheral vascular
Abbas Ferdosi M.D.
Oct. 2014
Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock
Holger Thiele, M.D., Uwe Zeymer, M.D., Franz-Josef Neumann, M.D., Miroslaw Ferenc, M.D.,
Hans-Georg Olbrich, M.D October 10, 2012
CONCLUSIONS
The use of intraaortic balloon counterpulsation did not significantly reduce 30-day
mortality in nupatients with cardiogenic shock complicating acute myocardial
infarction for whom an early revascularization strategy was planned. (Funded by the
German Research Foundation and others; IABP-SHOCK II ClinicalTrials.gov
mber, NCT00491036.)
Abbas Ferdosi M.D.
Oct. 2014
Extra Corporeal Membrane Oxygenation
(ECMO)
• A form of extracorporeal life
support where an external
artificial circuit carries venous
blood from the patient to an
oxygenator where blood becomes
enriched with oxygen and has
carbon dioxide removed.
Abbas Ferdosi M.D.
Oct. 2014
ECMO
• The blood is than returned to the patient via a central vein
or an artery.
Abbas Ferdosi M.D.
Oct. 2014
ECMO cannulation
Abbas Ferdosi M.D.
Oct. 2014
ECMO cannulation
Abbas Ferdosi M.D.
Oct. 2014
ECMO function
• Reduction of preload and afterload
• Oxygenation of the blood
Abbas Ferdosi M.D.
Oct. 2014
ECMO indication
 Cardiogenic shock
 Post cardiotomy
 Bridge to HTX/VAD
 Graft failure
 Myocarditis
 ECMO-CPR
Abbas Ferdosi M.D.
Oct. 2014
ECMO Contraindications
 Severe calcific aorto- iliac disease or peripheral vascular
 Multi-Organ Failure
 End-stage Disease
Abbas Ferdosi M.D.
Oct. 2014
ECMO complication
 Peripheral arterial disease
 Compartment syndrome
Abbas Ferdosi M.D.
Oct. 2014
Impella
 The smallest heart pump in the world
 9 Fr catheter, 12 Fr / 14Fr microaxial
 Produces 2.5 / -4 L / min forward flow
Increases:
 coronary flow
 the systemic flow
 cardiac output
which is in direct correlation to mortality
Abbas Ferdosi M.D.
Oct. 2014
Impella
Discharges directly to the Ventricle:
 The pump pumps the blood from the LV
 Resulting in a reduction of the wall voltage
 Reduction of O2 demand in the myocardium
 While at the same time increases the O2 supply
Regardless of the heart rhythm
and catecholamines
Abbas Ferdosi M.D.
Oct. 2014
2
5
Physiological effect of Impella support
HCS-PP00022-004 rA EU
Abbas Ferdosi M.D.
Oct. 2014
Impella® Controller (AIC)
Impella Controller (AIC) for monitoring
and control of the Impella pump and the
purge system.
Abbas Ferdosi M.D.
Oct. 2014
Promotion of blood
 The rotating drive sucks blood through the
cannula
 Impella controller (AIC) controls the rotation
speed of the drive
 The rotational speed is proportional to the flow
 Faster rotation = Higher flow
Motor
Abbas Ferdosi M.D. rA EU
HCS-PP00022-006
Impeller
cannula
Oct. 2014
Impella
Impella® Circulatory Support Platforms
Impella 2.5
Impella CP
Impella 5.0
Impella LD
Flow Rate (L/min)
2.5
3.7 – 4.0
5.0
5.0
Circulatory Support
Partial
Partial - High
High-flow
High-flow
Catheter Size
9 Fr
9 Fr
9 Fr
9 Fr
Pump Size
12 Fr
14 Fr
21 Fr
21 Fr
Insertion Method
Percutaneous
Percutaneous
Arterial Cut down
Surgical Insertion
Abbas Ferdosi M.D.
Oct. 2014
Impella
Abbas Ferdosi M.D.
Oct. 2014
Myocardial Protection … O2 Supply
Increased Myocardial Blood Flow, Aqel et al. (2009)
Blood Flow
(Coronary Arteries
& Microvasculature)
a
AOP
MR
Improvement in Myocardial Perfusion
with Impella Support (Tc-99 MIBI
Imaging)
Impella OFF
Aortic
Pressure
(AOP)
Microvascular
Resistance (MR)
Abbas Ferdosi M.D.
Under-perfused
area
Impella ON
Impella increases
perfusion
Oct. 2014
Myocardial Protection … O2 Supply
Unloading Reduces Infarct Size…Impella vs IABP Meyns et al., JACC (2003)
Abbas Ferdosi M.D.
Oct. 2014
Circulation. 2012 Oct 2;126(14):1717-27.
10.1161/CIRCULATIONAHA.112.098194. Epub 2012 Aug 30.
A prospective, randomized clinical trial of hemodynamic support with
Impella 2.5 versus intra-aortic balloon pump in patients undergoing
high-risk percutaneous coronary intervention: the PROTECT II study.
O'Neill WW1, Kleiman NS, Moses J, Henriques JP, Dixon S, Massaro J, Palacios I, Maini B, Mulukutla S, Dzavík V, Popma
J, Douglas PS, Ohman M.
CONCLUSIONS:
The 30-day incidence of major adverse events was not different for patients with
IABP or Impella 2.5 hemodynamic support. However, trends for improved outcomes
were observed for Impella 2.5-supported patients at 90 days.
Abbas Ferdosi M.D.
Oct. 2014
Conclusion
Early mechanical support of the heart reduces
mortality in cardiogenic shock.
Abbas Ferdosi M.D.
Oct. 2014
Tank you
for
your attention
Abbas Ferdosi M.D.
Oct. 2014

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