Acute Mechanical Circulatory Support for Cardiogenic Shock

Navin K. Kapur, MD, FACC, FSCAI, FAHA, is a dual, board-certified Interventional Cardiologist and Advanced Heart Failure/Cardiac Transplant specialist. He is Director of the Acute Circulatory Support Program and Associate Director of the Cardiac Catheterization Laboratory at Tufts Medical Center. His clinical expertise focuses on invasive hemodynamics, mechanical circulatory support, and interventional therapies for patients with advanced heart failure. As Director of the Interventional Research Laboratories ‪@tuftsmedicine‬, Dr. Kapur’s translational research focuses on large animal models of acute and chronic heart failure, circulatory support device development, and cardioprotective mechanisms in the setting of acute myocardial infarction. His recent work has focused on the hypothesis that mechanically unloading the heart and delaying coronary reperfusion limits infarct size. This concept, known as the 'mechanical conditioning hypothesis' has the potential to alter the paradigm of acute heart attack therapy and reduce the burden of ischemic heart failure. 0:00 Introduction 3:57 The Field of MCS: Robust with Innovation 5:59 If you manage CG-Shock in 2017 you should be an Acute MCS Specialist 8:20 The Spectrum of Acute MCS Devices in 2017 9:46 Hemodynamic Efficacy Without Clear Clinical Benefit in Small RCTs Comparing Acute MCS Options 10:26 Left Ventricular Unloading A Fundamental Target of Therapy for Acute MCS 14:18 Hemodynamic Principles of Rotary Flow Pumps Higher Flow with Lower Transvalvular Pressure Gradient 15:40 Trans-valvular AMCS Devices Axial Flow Pump: Impella "LV-Direct" Cannulation 16:33 Axial Flow Catheter (Impella): Unloading Characteristics 17:05 Impella: Troubleshooting Tip Monitor for Hemolysis in Cardiogenic Shock Use pf-Hb not LDH alone 18:20 Next Generation Axial Flow Catheter: Heartmate PHP (St. Jude/Thoratec) 14Fr Sheath → 24Fr Impeller 19:26 Peripheral Cannulation VA-ECMO (RAFA Bypass) 21:00 VA-ECMO: LV Loading 22:38 VA-ECMO is a Bridge to Durable LV Support or OHTX Not a Bridge to Recovery in Advanced Heart Failure 23:50 VA-ECMO: Troubleshooting Tip Monitor and Prevent Limb Ischemia 26:10 The Hemodynamic Support Equation for Acute MCS 27:40 Solving the Hemodynamic Support Equation with AMCS 28:32 We don't use hemodynamic data to guide decision-making often enough 30:52 Defining Hemodynamic Profiles of Cardiogenic Shock 31:29 Shock Profiles and Outcomes with Impella & VA-ECMO 33:00 Hemodynamic Formulas to Assess RV Function 33:34 Hemodynamic Signatures of RV Failure The Pulmonary Artery Pulsatility Index (PAP) 34:09 Matching Patients and AMCS Pumps The Tufts Cardiogenic Shock Algorithm 37:18 Have an Exit Strategy Ideally Before Initiating Acute Mechanical Circulatory Support 38:05 Who do you want on your Shock Team? 38:53 Durable MCS Devices are Not Commonly used for Acute Circulatory Support 41:35 Full Body Recovery: Quantifying Ambulation among Impella 5.0 Patients - The Lazarus Study 42:29 Percutaneous Axillary/Brachial Impella CP 43:08 Don't ignore the RV in shock Impella vs VA-ECMO for RV Support? 45:33 Impella 5.0 LVAD Activation Hemodynamics 46:14 Percutaneous Support for RV Failure 46:27 Impella 5.0 + RP Activation Hemodynamics 47:54 Pre-Operative Hemodynamics 48:11 Post-Operative Course Decision Made: Bridge to Transplant 48:29 Bipella (CP+RP) Bridge to Recovery 49:22 When Skating on Thin Ice, Safety is in Speed 50:33 Cardiogenic Shock: IABP Support Pre-PCI 53:27 New Directions: LV Unloading: Engineering Hope For the Hopeless 53:59 DTU Safety & Feasibility Study 54:31 Interventional Heart Failure A Tufts Trademark 55:22 It Takes Teams of Teams !