cardiogenic shock subtypes

Characteristics of Cardiogenic Shock Subtypes for Guiding Clinical Practice

May 18, 2018

Key Takeaways

  • Patients with cardiogenic shock (CS) due to end-stage heart failure (ESHF) who receive mechanical circulatory support (MSC) have lower global oxygen delivery, greater anaerobic metabolism, lower pulmonary capacitance, and higher pulmonary vascular resistance than patients with CS due to acute myocardial infraction (AMI).

Table 1. Types of Supporta

Primary Support (n, %) CS Due to AMI (n = 26) CS Due to ESHF (n = 42)
Impella 5 (20%) 3 (7%)
VA ECMO 13 (50%) 17 (40%)
BIVAD 4 (15%) 19 (46%)

aData from Lim et al1

 

Patients with CS due to ESHF had significantly lower ejection fraction compared with patients with CS due to AMI (13±2 vs 25±3, respectively; P<0.001). Additionally, patients in the ESHF group presented with lower pulmonary capacitance (1.33±0.20 vs 2.18±0.28 ml/mmHg, P<0.001) and higher pulmonary vascular resistance (3.72±0.52 vs 2.23±0.23 WU, P<0.001).

The Impella CP device was inserted through the femoral vessels in all cases. Two lower-limb amputations occurred with VA ECMO vs 0 amputations in the Impella heart pump group.

While ESHF patients had greater anaerobic metabolism than AMI patients, those with ESHF vs AMI exhibited different patterns of metabolic derangement with significant differences in pH (ESHF [7.32±0.09] vs AMI [7.20±0.02]; P<0.001), sodium (ESHF [129.7±1.1] vs AMI [137.2±1.0]; P<0.001), and chloride (ESHF [91.9±0.8] vs AMI [101.9±1.0]; P<0.001) ions.

According to the investigators, this study highlights the importance of understanding the “phenotypic differences [which] may guide intervention based on the underlying etiology of cardiogenic shock.”

This study is limited by its small sample size as well as its single-center design. Despite this limitation, this study provides greater insight into the characteristics of highly selected CS patients with ESHF and AMI than previously published research.

Reference:

  1. Lim HS, Howell N. Cardiogenic Shock Due to End-Stage Heart Failure and Acute Myocardial Infarction: Characteristics and Outcome of Temporary Mechanical Circulatory Support. Shock [published online November 3, 2017]. doi: 10.1097/SHK.0000000000001052.

NPS-168-17

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Impella® Device — Indication & Safety Information

INDICATIONS FOR USE

Protected PCI

The Impella 2.5® and Impella CP® Systems are temporary (≤ 6 hours) ventricular support devices indicated for use during high-risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease, when a heart team, including a cardiac surgeon, has determined high-risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 and Impella CP Systems in these patients may prevent hemodynamic instability, which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.

Cardiogenic Shock

The Impella 2.5®, Impella CP®, Impella 5.0®, and Impella LD® Catheters, in conjunction with the Automated Impella Controller (collectively, “Impella® System Therapy”), are temporary ventricular support devices intended for short term use (≤ 4 days for the Impella 2.5 and Impella CP, and ≤ 6 days for the Impella 5.0, and Impella LD) and indicated for the treatment of ongoing cardiogenic shock that occurs immediately (< 48 hours) following acute myocardial infarction or open heart surgery or in the setting of cardiomyopathy, including peripartum cardiomyopathy, or myocarditis as a result of isolated left ventricular failure that is not responsive to optimal medical management and conventional treatment measures (including volume loading and use of pressors and inotropes, with or without IABP). The intent of Impella System Therapy is to reduce ventricular work and to provide the circulatory support necessary to allow heart recovery and early assessment of residual myocardial function.

Important Risk Information for Impella devices

CONTRAINDICATIONS

The Impella 2.5, Impella CP, Impella 5.0 and Impella LD are contraindicated for use with patients experiencing any of the following conditions: Mural thrombus in the left ventricle; Presence of a mechanical aortic valve or heart constrictive device; Aortic valve stenosis/calcification (equivalent to an orifice area of 0.6 cm2 or less); Moderate to severe aortic insufficiency (echocardiographic assessment graded as ≥ +2); Severe peripheral arterial disease precluding placement of the Impella System; Significant right heart failure*; Combined cardiorespiratory failure*; Presence of an Atrial or Ventricular Septal Defect (including post-infarct VSD)*; Left ventricular rupture*; Cardiac tamponade*

* This condition is a contraindication for the cardiogenic shock indication only.

POTENTIAL ADVERSE EVENTS

Acute renal dysfunction, Aortic valve injury, Bleeding, Cardiogenic shock, Cerebral vascular accident/Stroke, Death, Hemolysis, Limb ischemia, Myocardial infarction, Renal failure, Thrombocytopenia and Vascular injury

In addition to the risks above, there are other WARNINGS and PRECAUTIONS associated with Impella devices. Visit http://www.abiomed.com/important-safety-information to learn more.

Right-Side Support – Indication & Safety Info.

INDICATIONS FOR USE

The Impella RP® System is indicated for providing temporary right ventricular support for up to 14 days in patients with a body surface area ≥1.5 m2, who develop acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery.

Important Risk Information for Impella RP

CONTRAINDICATIONS

The Impella RP System is contraindicated for patients with the following conditions: Disorders of the pulmonary artery wall that would preclude placement or correct positioning of the Impella RP device. Mechanical valves, severe valvular stenosis or valvular regurgitation of the tricuspid or pulmonary valve. Mural thrombus of the right atrium or vena cava. Anatomic conditions precluding insertion of the pump. Presence of a vena cava filter or caval interruption device, unless there is clear access from the femoral vein to the right atrium that is large enough to accommodate a 22 Fr catheter.

POTENTIAL ADVERSE EVENTS

The potential adverse effects (eg, complications) associated with the use of the Impella RP System: Arrhythmia, Atrial fibrillation, Bleeding, Cardiac tamponade, Cardiogenic shock, Death, Device malfunction, Hemolysis, Hepatic failure, Insertion site infection, Perforation, Phlegmasia cerulea dolens (a severe form of deep venous thrombosis), Pulmonary valve insufficiency, Respiratory dysfunction, Sepsis, Thrombocytopenia, Thrombotic vascular (non-central nervous system) complication, Tricuspid valve injury, Vascular injury, Venous thrombosis, Ventricular fibrillation and/or tachycardia.

In addition to the risks above, there are other WARNINGS and PRECAUTIONS associated with Impella RP®. Visit http://www.abiomed.com/impella/impella-rp to learn more.

General Indication and Safety Information

To learn more about the Impella platform of heart pumps, including important risk and safety information associated with the use of the devices, please visit: www.protectedpci.com/indications-use-safety-information/