Modelli gestionali nello scompenso cardiaco

(1)

hh

Cardiochirurgia Ospedale S.Martino Genova

Modelli gestionali nello

scompenso cardiaco:

Trattamento chirurgico

nella fase di

instabilizzazione

Luigi Martinelli

U.O. CARDIOCHIRURGIA

(2)

RUOLO DELLA CARDIOCHIRURGIA NEL

TRATTAMENTO DELLO SCOMPENSO

• RECUPERO PAZIENTI CON SHOCK CARDIOGENO

• TRATTAMENTO EZIOLOGICO DELLO SCOMPENSO

– IM funzionale (post ischemica, CMD) – Rivascolarizzazione “estrema”

– Ricostruzione VS

– Applicazione devices “passivi”

• ASSISTENZA CIRCOLATORIA MECCANICA

– Svezzamento

– Ponte al trapianto – Terapia definitiva

(3)

THE PROBLEM

• FAILING CIRCULATION / CARDIAC

ARREST IN E.R.

• STANDARD RESUSCITATION

• PENDING OR PERSISTENT CARDIOGENIC

(4)

FURTHER CLINICAL

EVALUATION

• Neurological status

• Extracardiac problems

• Age

POSSIBLE APPROACHES

• Conservative

• Advanced

(5)

If the heart is not the culprit

organ

CONSERVATIVE SUPPORT

• INOTROPES

• VENTILATION

• ETHIOLOGICAL TREATMENT

(MEDICAL, SURGICAL)

(6)

BASIC CARDIAC

EVALUATION

• CLINICAL HISTORY

• ECG

• TROPONIN I / MYOGLOBIN

• ECHOCARDIOGRAPHY

NON SURGICAL

SURGICAL

(7)

MI/ACUTE CORONARY SYNDROME

ANGIOGRAPHY/PTCA

IABP

MYOCARDITIS DILATED CARDIOMYOPATHY

I.V. FARMACOLOGICAL SUPPORT

IABP

MECHANICAL CIRCULATORY SUPPORT

DISCHARGE DISCHARGE

NON SURGICAL CONDITIONS

(8)

DISCHARGE

MECHANICAL

COMPLICATION OF MI (MITRAL VALVE, FREE WALL, SEPTUM)

MECHANICAL CIRCULATORY SUPPORT

MASSIVE

PULMONARY EMBOLISM TAMPONADE

DISCHARGE

SURGERY

SURGICAL CONDITIONS

(9)

MECHANCAL CIRCULATORY

SUPPORT

PRE-REQUISITES:

• PRESUMED NEUROLOGICAL RECOVERY

• ABSENCE OF PRE-EXISTING MOF

GOALS

• CARDIAC RECOVERY

• HTX

(10)

Two-Axis Categorization

Technology

TandemHeart Impella

acute

Raitan Pump Orqis System 98 XT ACAT/AutoCAT

Percutaneou

s

Impella elect/recover A-Syst/ParaFlow Thoratec VAD BCM Medos VAD BVS-5000 Kantrowitz Berlin Heart FIBAP

Paracorporea

l

Levitronics VAD CorAid HeartMate II TILVAS Incor I + II Jarvic 2000 DeBakey HeartQuest VentrAssist Kriton Streamliner Novacor HeartMate HeartSaver LionHeart AbioCor

Implanted

Rotary

Displacement

Application

(11)

Intra Aortic Balloon Pump

Datascope/Arrow

(12)

(13)

Theory of Operation

RV Pump:

– Pushes blood from

the right atrium

through the

catheter into the

pulmonary artery

LV Pump:

– Pulls blood out of

LV through the

catheter into the

aorta

(14)

Impella

• very short term

application (_{≤3hrs "elect";} recover 7 days)

• increased hemolysis risk due to high RPM • labor intensive (continuous monitoring by trained personnel) • require systemic anticoagulation • surgical im-/explantation required

• left and right heart support

• relatively inexpensive • full patient support

• relatively simple setup

Disadvantages

Advantages

(15)

TANDEM HEART pVAD

• Continuous flow

• Removes oxygenated blood from

LA via Transseptal Cannula placed

in the femoral vein

• Returns blood via femoral artery

• Has been shown to:

– Reduce LAP and PCWP

– Reduces myocardial oxygen demand

– Increase MAP, CO

(16)

Transseptal Cannulation

• Access to LA via standard

transseptal technique

• Catheter exchanges made

with Valvuloplasty

guidewire or Amplatz soft

tip wire

• Dilate septum with

2-stage (14/21 Fr.) dilator

• Place cannula in LA

(17)

Biomedicus Centrifugal

Pump

(18)

(19)

EQUIPMENT

•Centrifugal pumps

•Monitors and systems

•Circuit configurations

•Other issues

(20)

Centrifugal Pumps

• labor intensive (continuous monitoring by trained personnel) • hemolysis risk increased after 6hrs • bleeding • require systemic anticoagulation • surgical im-/explantation required • very short term

application • easy setup

• simple pump exchange • inexpensive

Disadvantages

Advantages

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POST CARDIOTOMY MECHANICAL SUPPORT

RESULTS

• POPULATION

: 1.5% OF CARDIAC

OPERATION (USA 2003)

• OUTCOMES

: 20-40%DISCHARGE

• COMPLICATIONS

:

BLEEDING 25-45% » RENAL FAILURE 20-30 » MOF 20-25% » THROMBOEMBOLISM 4-20% » STROKE 5-20% » INFECTIONS 35%-60%