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Table56.1 Continued

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First author (Reference)

Acharya

Yea r Patients

(nr.)

Preop mechanical support (%)

2016 5496 82% (periop)

2.3%

Type of preop temporary support

IABP MCS (Impella® the most common device)

Cardiac arrest at sternotomy or prior to surgery

22% (not known if during or prior)

LITA use (%) Postop

cardiogenic shock or cardiac

Postop mechanical support

Type of postop temporary support

arrest

n.a. n.a. 5.3% ECMO (the most

common device)

HTx (%) Long-

lasting VAD (%)

In- hospital survival (%)

n.a. n.a. 18.7%

(37.2% for pts with preop MCS,

58.4% for pts with postop MCS,

Long- term survival

n.a.

58.3% in salvage CABG)

Gaudino

2016 67 n.a. n.a. n.a. 47 (70.1%) n.a. n.a. n.a. n.a. n.a. 58 (86%) 43 (74%) at 78 ±

48months

Davierwala

Rohn

2016 508 52.9%

3.1%

2017 135 27%

(8.9% intraop)

IABP

30.4% 90.3% 42.7% 23%

ECMO

IABP n.a. 53%

(33% total arterial

15.2%

ECMO

27% 6.7% ECMO

IABP

n.a. n.a. 33.7% 42.6% at 5years

33.4% at 10years

n.a. n.a. 8.1% (30- day) n.a.

revascularization)

Butt

2018 37,495 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 97.6% (30day) 35.6% at 1year

67.4% at 7years

Cox

Liakopoulos

2018 5259 n.a. n.a. 1168 (22.2%) n.a. n.a. n.a. n.a. n.a. n.a. 4416 (84%) n.a.

a 17

2019 470 149 (31.8%) IABP 187 (39.9%) 390 (83.1%) n.a. 245 (52.1%) IABP 94.9%

ECMO 5.1%

n.a. n.a. 19.8% (15.4%

in NSTEMI, and

n.a.

23.9% in STEMI)

Included also patients with AMI- related complications and combined valve surgery.

ECMO, extracorporeal membrane oxygenation; HTx, heart transplant; IABP, intra- aortic balloon pump; LITA, left internal thoracic artery; MCS, mechanical circulatory support; n.a., not applicable; NSTEMI, non ST- elevation myocardial infarction; pts, patients; STEMI, ST- elevation myocardial infarction; VAD, ventricular assist device.

56 Management and impact of cardiogenic shock/cardiac arrest 389

(a)

(b)

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Cannulation of the Femoral Vessels

(Peripheral ECMO Conﬁguration)

for CPB and CABG (VG use only)

Switch from CPB to VA ECMO

Using the Femoral Cannulas (+ Distal Perfusion Catheter) In Case of Difﬁcult Weaning

or High Inotropes

Ao Valve Opening or

Minimal LV Contactility

(good pulsatility of the systemic

blood pressure,

no LV distension)

ECMO Alone

Recovery No Recovery (4–7 days)

Femoral Vessel Cannulation and VA ECMO

(Peripheral VA ECMO Conﬁguration

+ Distal Perfusion Catheter)

Persistence or Worsening

of Preoperative LV Dysfunction

TOE

(aortic valve function

and residual heart function)

Protracted

Ao Valve Closure

or Standstil

Heart/

LV distension

Add IABP or Impella

or Other LV Venting (left atrium)

Long Term MCS/HTx

Femoral Vessel Cannulation and ECMO

(Peripheral VA ECMO Conﬁguration)

Doubt on CABG Quality

Coronary Angiography

No CABG Graft

Dysfunction

RE-CABG

if No Immediate ROSC

+ Distal Perfusion Catheter)

Cardiac Tamponade

CABG Graft

Dysfunction

PCI or

Tamponade

No Recovery

Immediate

Chest

Opening

Fluid

Evacuation

Recovery

Quick Central Cannulation

CABG (VG use only)

Prophylactic IABP

(Placement Before CPB Weaning)

Intraoperative Post-CPB TOE

(RV and LV evaluation,

aortic valve function)

Persistent

RV or Biventricular

Dysfunction

Add VA ECMO (peripheral + distal perfusion catheter)

Recovery

Persistent Isolated

LV Dysfunction

Refractory*

Haemodynamic Instability

Quick Central or

Peripheral Cannulation

for CPB and CABG

(VG use only)

Add Impella or VA ECMO

and Reassess in ICU

for MCS Adequacy

(lactate, LV distension,

inotropic dosage...)

No Recovery (4–7 days)

Controlled**

Haemodynamic Instability

Quick Central or

Peripheral Cannulation

for CPB and CABG

(LIMA Harvesting

on Pump)

Recovery

IABP/Impella for

Islolated LV Dysfunction

or VA ECMO for RV or Biventricular Dysfunction

(peripheral + distal perfusion catheter)

Long-Term MCS/HTx

Ischaemic ECG Changes

Coronary Angiography

No Graft

Dysfunction

Persistent

LV, RV, or Biventricular Dysfunction

Graft

Dysfunction

PCI or

RE-CABG

Tamponade

No Recovery

+ direct or percutaneous

No Ischaemic ECG

TOE Echo

Isolated RV

Support

(Peripheral vein

PS cannulation

Changes

Tamponade

Chest

Opening

Fluid

Evacuation

Recovery

Fig.56.1 (a) Algorithm for intraoperative and perioperative management in patients with cardiac arrest and undergoing or submitted to isolated

coronary artery bypass grafting without mechanical complications of acute myocardial infarction. (b)Algorithm for intraoperative and perioperative management in patients with cardiogenic shock and undergoing or submitted to isolated coronary artery bypass grafting without mechanical complications of acute myocardial infarction. Ao, aortic; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; CPR, cardiopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation; HTx, heart transplant; IABP, intra- aortic balloon pump; ICU, intensive care unit; LV; left ventricular; MCS, mechanical circulatory; ROSC, return of spontaneous circulation; PCI, percutaneous coronary intervention; RV, right ventricular; TOE, transoesophageal; VA, veno- arterial.

390 SECTION 7 Technical aspects ofcoronary artery bypass graft surgery

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Table56.2 Summary ofcurrently available short- term mechanical circulatory supports

IABP TandemHeart® Imeplla® 5.0 CentriMag® ECMO

Flows (L/ min) Max. 0.5– 1.0 Max. 4.0 Max. 5.0 Max. 9.0 Max. 7.0– 8.0

Insertion/ placement Percutaneous/ femoral

artery

LV unloading + + ++ ++++ dependent on LV ejection

Advantages Quick placement

Low adverse proﬁle

Disadvantages Provides minimal

support

BiVAD, biventricular assist device.

Percutaneous/ femoral artery + vein

Percutaneous system Full left- sided support

Costly Transseptal puncture Cannula migration

Surgical/ femoral or axillary artery

Mobile patient

Cannula dislodgement Limb ischaemia

Surgical/ central Percutaneous or surgical/

Left/ right or BiVAD Can be coupled with oxygenator

Surgical placement Bleeding

peripheral or central

or LV vent

Maximal cardiorespiratory support

Limb ischaemia Immobile patient

and, in particular, in relation to the extent of support and eectiveness of LV decompression are presented in Table 56.2.

In an elegant investigation of the Society of oracic Surgeons National Database, Acharya and colleagues described various systems used to achieve circulatory support in the setting of AMI prior to and aer coronary surgery. e study ndings demonstrated that almost 15% of patients with preoperative MCS remained on support aer surgery, whereas only 5% of patients with post- AMI CS without circulatory assistance, required de novo postoperative haemodynamic support (Fig. 56.2). Furthermore, in the patients with preoperative circulatory support, the Impella® device (Abiomed, Danvers, MA, USA) was by far the most common assistance prior to surgery, while ECMO constituted the majority of MCS aer surgery (Fig. 56.2).

Interestingly, there was a negligible number of patients receiving a ventricular assist device (VAD) soon aer surgery, and a rather high number of patients still received an Impella® device aer surgical revascularization. Combinations of devices were also applied, mainly VAD and ECMO. Notably, this study did not report the rate of IABP application, although this device still represents the most commonly used circulatory assist device used in the operating room.

Intra- aortic balloonpump

e IABP is a circulatory support device that is placed via a peripheral artery and is positioned in the descending thoracic aorta. Ideally, the tip of the balloon is situated 1– 2cm below the origin of the le subclavian artery and the distal end of the balloon should remain above the renal artery branches (Fig. 56.3).

Placement should generally be conrmed via transoesophageal echocardiography, uoroscopy, or— at a minimum— chest X- ray. e balloon should not be completely occlusive in the aortic lumen during ination, and should comprise approximately 85– 90% of the luminal diameter to prevent trauma to platelets and red blood cells. An IABP functions via counterpulsation, rapidly inating during diastole and actively deating during systole. e eects of this include a rapid increase in blood pressure during early diastole (diastolic augmentation) and reduced aerload during early systole. e main eects of an IABP are reduction of ventricular aerload, improvement in diastolic coronary perfusion, and enhancement of subendocardial perfusion. In addition to increasing

diastolic perfusion pressure, IABP counterpulsation has also been shown to facilitate the redistribution of coronary blood ow to areas of ischaemic myocardium, thus improving cardiac function and/ or preventing ongoing injury.

Despite the introduction of the IABP in 1962, there are still no standardized criteria for its use in CABG patients, and controversy still exists regarding the optimal timing of IABP placement and initiation of therapy. In 2012, the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP- SHOCK- II) trial, which randomized post- AMI CS patients to IABP in association with pharmacological therapy versus pharmacological treatment alone did not show any signicant benet with regard to 30- day, 1- year, and 5- year survival.–  Aer the publication of this study, the use of IABP in post- AMI CS declined substantially, but had limited inuence on perioperative use.

e IABP is typically inserted preoperatively, perioperatively, or postoperatively depending on an individual surgeon’s judgement. According to the Benchmark Registry and Society of oracic Surgeons National Database, IABP procedures were initiated preoperatively in 52– 64% of all cases in which an IABP was used. When an IABP is inserted perioperatively or postoperatively, it is oen by necessity to rescue from CS or failure to wean from CPB. Consequently, timing of insertion has been associated with varied in- hospital mortality rates: preoperative insertion carries a mortality of around 19%; intraoperative insertion, 28– 32%; and postoperative insertion, 39– 41%.

ere remains, however, considerable debate regarding preoperative use of an IABP in high- risk CABG patients. Several retrospective and randomized controlled studies have investigated the utility of preoperative IABP placement in high- risk CABG patients. Most randomized controlled trials on the subject have been conducted by Christenson etal., who dened high risk as at least two of the following:LV ejection fraction less than 30% or 40%, unstable angina, and le main stenosis greater than 70%. ACochrane review of six available randomized controlled trials examined aggregate data from 255 patients, 105 of whom were allocated to preoperative IABP and 88 who received no preoperative intervention. ere were four hospital deaths in the intervention arm and 23 in the non- intervention arm (odds ratio (OR) 0.18, 95% condence interval (CI) 0.08– 0.41; P <0.0001). Additionally, low cardiac index (<2.0 L/ min/ m) was documented in 21/ 105 patients in the

56 Management and impact of cardiogenic shock/cardiac arrest 391

(a)

VAD + Impella

VAD+Tandem

ECMO+Impella

VAD+ECMO+Tandem

VAD+ECMO+Impella

* The Impella/ECMO* group consists of 19 patients who had preoperative MCS (14 Impella, 5 ECMO) who continued

100

120

100

120

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MI and cardiogenic shock (N = 5496)

Preoperative MCS (N = 129)

Postoperative MCS

(N = 19)

(b)

Impella

to have postoperative MCS (13 VAD, 5 ECMO, 1 VAD+ECMO)

(c)

No postoperative MCS

(N = 110)

Impella/ECMO* ECMO ECMO+Impella

Intraoperative/ postoperative MCS (N = 279)

No preoperative MCS (N = 5367)

No intraoperative/ postoperative MCS (N = 5088)

VAD

ECMO

Fig.56.2 (a) Patient subgroups by mechanical circulatory support (MCS) status. (b)Types of preoperative MCS. (c)Types of intraoperative/

postoperative mechanical circulatory support:extracorporeal membrane oxygenation (ECMO), ventricular assist device (VAD), Impella®, VAD plus ECMO, Tandem, VAD plus Impella®, VAD plus Tandem, ECMO plus Impella®, VAD plus ECMO plus Tandem, and VAD plus ECMO plus Impella®

Impella

VAD+ECMO

Tandem

(Tandem=TandemHeart® percutaneous ventricular assist device; CardiacAssist, Pittsburgh, PA, USA).

Reproduced from Acharya D., Gulack BC, Loyaga- Rendon RY, etal. Clinical characteristics and outcomes of patients with myocardial infarction and cardiogenic shock undergoing coronary artery bypass surgery:data from the Society of Thoracic Surgeons National Database. Ann Thorac Surg 2016;101:558– 66 with permission from Elsevier.

treatment arm and 59/ 88 in the non- treatment arm (OR 0.14, 95% CI 0.08– 0.25; P <0.0001), with a large portion of patients in the non- treatment group requiring IABP placement postoperatively for low cardiac index (52/ 88). Outcomes at 2years demonstrated no

signicant dierence in overall mortality among survivors of the index hospitalization in this small patient sample.

In addition to several randomized controlled trials, there are

multiple cohort studies that have addressed the use of preoperative

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deaths in the control group. e pooled odds ratio for hospital mortality was 0.41 (95% CI 0.21– 0.82; P=0.01). e absolute risk reduction was 6% (95% CI 2– 10%; P=0.007), and the number needed to treat was 17 (95% CI 10– 50). Moreover, it has been recommended that non- emergent high- risk patients (i.e. severe LV function, le main or complex coronary artery disease) should also undergo preoperative IABP insertion due to reduced mortality and morbidity as demonstrated by several recent meta- analyses.,

One of the main drawbacks to IABP placement is the invasive nature of the procedure, as well as the potential for associated complications. Typical complications include arterial thrombosis, limb ischaemia, and haematoma. Occasionally, injury to the arterial system requiring surgical repair at the point of IABP insertion has also been reported, although this appears to be an uncommon complication. e overall complication rate appears to be between 2% and 5% with most complications resolving completely aer removal of the IABP.

IABP and off- pumpCABG

Several studies have examined preoperative use of an IABP in highrisk patients undergoing o- pump CABG. Kim etal. conducted a retrospective review of 142 high- risk patients undergoing o- pump

Fig.56.3 Intra- aortic balloon pump.

CABG. Although the intervention arm (57 patients) had a higher number of high- risk patients than the control arm (85 patients), there was no signicant dierence in mortality between the two

IABP for high- risk CABG. Feola etal. in 1977 investigated preoperative IABP use in 25 patients and compared the outcome to 23 patients in the control group who did not receive a preoperative IABP. All patients had an LV ejection fraction less than or equal to 30% and were NewYork Heart Association classIII or IV. Hospital mortality was 35% (8/ 23) in the control group and 8% (2/ 25) in the treatment group (P <0.05). However, the study size was small and the control group mortality was relatively high. Holman etal. utilized propensity matching to compare 550 patients who received preoperative IABP with 550 patients who did not. Inclusion criteria included high- risk CABG patients but who were haemodynamically stable. Patients were matched based on age, sex, renal failure, heart failure, diabetes, comorbidity score, le main coronary stenosis greater than 70%, and redo CABG. No signicant dierences in hospital mortality or 1- year survival were noted between the two cohorts. Length of stay was, however, signicantly shorter in favour of the preoperative IABP group (P <0.005). Both Dietl and colleagues and Gutnger and co- workers also evaluated preoperative IABP placement in high- risk CABG patients., Dietl etal. reported that although the IABP group had a higher prevalence of redo CABG, NewYork Heart Association classIII or IV, recent myocardial infarction, emergent surgery, and le main stenosis, the 30- day mortality was 2.7% (1/ 37) in the IABP group versus 11.9% (15/ 126) in the control group. Gutnger etal. also demonstrated that despite having a signicantly higher prevalence of AMI, congestive heart failure, and lower LV ejection fraction prior to surgery, the 30- day mortality rate was 2.8% (3/ 109) in the control group versus 6.2% (6/ 97) in the intervention arm. e absence of a signicant dierence in mortality was considered to be evidence of benet.

A meta- analysis of several randomized control trials and cohort studies with a control group evaluated a total of 2363 patients, 1034 of whom received a preoperative IABP and 1329 who did not. Overall there were 49 deaths in the IABP group compared to 110

groups. Additionally, conversion to on- pump CABG was similarly low in both groups. Suzuki etal. also reported on high- risk patients undergoing o- pump CABG. irty- two patients received preoperative IABPs while 101 patients served as controls. Again, despite the IABP group having a higher proportion of unstable high- risk patients, morality was not signicantly dierent between the two groups. ere were no conversions to on- pump CABG in either group. Taken together, these results suggest that it is reasonable to employ the use of an IABP prior to high- risk o- pump CABG; however, additional investigation is necessary to further dene which patients may benet from this intervention.

In summary, preoperative IABP placement is reasonable, and may result in improved outcomes for high- risk patients undergoing CABG surgery. Despite the available evidence, no clear consensus guidelines exist for preoperative use of an IABP.

Veno- arterialECMO

ECMO is a closed- loop system that provides circulatory support as well as oxygenated blood (Fig. 56.4).

Unlike CPB, the ECMO circuit does not contain a venous reservoir, and as such the inammatory eect is signicantly reduced compared to CPB. is enables ECMO to be utilized as a short- term support device during periods of heart failure. Although the specics of ECMO technologies and a comprehensive review of the various strategies for their use are beyond the scope of this chapter, ECMO may be applied to patients in severe CS and AMI preoperatively, or those who fail to wean from CPB. Short- term support of several days duration is oen necessary prior to attempting weaning. e use of ECMO has signicantly increased since 2007 to treat patients with cardiac or respiratory failure.,, While the survival rate for these patients have improved, patients receiving ECMO for CS in the perioperative period remain unchanged with mortality rates between 30% and 50% along with unavoidable complications (i.e. bleeding, renal failure). e ECMO cannulation and circuit

56 Management and impact of cardiogenic shock/cardiac arrest 393

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Fig.56.4 VA ECMO via peripheral cannulation (femoral vessels).

strategy can be congured based on surgeon experience and unique patient characteristics. For instance, post- CABG biventricular failure can be treated by central or peripheral cannulation ECMO depending on the extent of peripheral vascular disease.

When choosing ECMO as a support strategy, it is important, however, to recognize that ECMO does not provide LV decompression, and as such it is necessary to adjust the ow to ensure that ejection through the aortic valve is preserved, to avoid stasis and thrombus formation on the native aortic valve or in the le cardiac chambers, particularly the le ventricle. In the event that heart function is too impaired to allow for LV ejection, it is necessary to place an LV vent or to use an Impella® pump to decompress the LV. Adjuncts to ECMO for improved unloading include the Impella® systems, TandemHeart® (Cardiac Assist, Inc, Pittsburgh, PA, USA), LV vent placement via a limited anterolateral thoracotomy, pulmonary artery catheter, or septostomy.

Biancari and colleagues have reported about the use of VA ECMO in 148 patients undergoing isolated CABG (0.6% out of 24,527

patients). Intraoperative ECMO implantation was carried out in 51% of the cases, and the remaining patients received similar temporary support with a mean delay of 17 (standard deviation

30)hours. Central cannulation was performed in 39% of the patients, and only 3.4% had LV venting (three cases through the right superior pulmonary vein, one from the apex, and one through the pulmonary artery, respectively). e overall in- hospital mortality was 64%, ranging from 34% to 100% in dierent institutions. Interestingly, the number of procedures was not directly associated with in- hospital survival. Lower survival was observed in patients with high lactate levels, ECMO duration longer than 3days, advanced age (if ≥70years), and in those with impaired creatinine clearance and pulmonary disease. Interestingly, in this group, there was no access to heart transplantation or le VAD aer ECMO in these post- cardiotomy patients.

Similar ndings were reported by Kim and associates in 0.5% of the overall CABG population in whom almost 40% of these patients experienced a mechanical complication of AMI. Continued postoperative support was required in almost 70%, indicating that persistent low cardiac output syndrome is common in these circumstances and should be taken into account when planning CPB and subsequent haemodynamic status. In their experience, successful weaning from ECMO was surprisingly good (91% of the patients), with an early mortality of 26%.

Prognostication is another important aspect, when temporary mechanical support is planned. Recently, Wang etal. addressed survival predictors in CABG patients receiving ECMO aer surgery. Arisk- score, named the REMEMBER Score, was designed and successfully implemented, showing superiority over other risk- score models, and the importance of older age, le main coronary disease, inotropic use, myocardial and renal injury and platelet numbers were useful parameters to predict patient outcome in this setting (Table 56.3).

Aer a period of continued haemodynamic stability on ECMO, with evidence of cardiac recovery, and normal neurological function, ECMO weaning can be initiated.,  If ECMO weaning is not possible, then decisions regarding long- term VAD or heart transplantation should be discussed by a Heart Team (Fig. 56.1).

Table56.3 The REMEMBER Score variables topredict outcome ofpatients undergoing ECMO afterCABG

Parameter

Age, years

<54 0 1 0

54– 67 1.783 5.95 (2.08– 17.06) 0.001 8

>67 2.384 10.85 (2.71– 43.41) 0.001 11

Left main disease

Inotropic score >75

CK- MB >130 IU/ L

Serum creatinine >150 μmol/ L

Platelet count <100 × 109/ L

OR odds ratio, CK- MB, creatine kinase- MB.

Left main disease was deﬁned as any stenosis ≥50% of the left main trunk.

Worse value within 6 hours prior to ECMO cannulation.

Reproduced from Wang L, Yang F, Xie H, Fan E, Ogino M, Brodie D, Wang H, Hou X.Predicting mortality in patients undergoing V- A ECMO after coronary artery bypass grafting:the REMEMBER Score. Crit Care 2019;23:11 (Attribution 4.0 International (CC BY 4.0)).

β Coefﬁcient

1.625 5.08 (2.05– 12.57) <0.001 7

1.126 3.08 (1.32– 7.21) 0.009 5

1.145 3.14 (136– 7.24) 0.007 5

1.496 4.46 (1.73– 11.53) 0.002 7

1.271 3.56 (1.50– 8.50) 0.004 6

OR (95% CI) P- value Score

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Other short- term ventricular assist devices (Impella®, TandemHeart®, iVAC2L®)

Currently available short- term VADs include the TandemHeart® systems (ProtekDuo® or ProtekSolo® cannula), Impella® systems, CentriMag® (oratec Company, Pleasanton, CA, USA), and iVAC2L® (Terumo, Leuven, Belgium) (Table 56.2). In the setting of CS, no major dierences were observed in short- term mortality between percutaneous short- term VADs versus IABP,,, while patients undergoing elective high- risk PCI beneted from percutaneous VAD support. On the other hand, large observational studies or randomized controlled trials are lacking in CABG patients. Several small cohort studies and case reports have demonstrated acceptable results in both preoperative CS and post- cardiotomy shock states.–  erefore, CS patients should be rst stabilized with an IABP and sent for immediate CABG. If haemodynamic deterioration ensues then a short- term percutaneous VAD should be considered. Alternatively, elective high- risk CABG patients who suer from post- cardiotomy shock despite IABP therapy will likely benet more from full cardiorespiratory support in the form of VA ECMO.

e Impella® device is a small, intracardiac microaxillary ow pump that can be placed percutaneously in the cardiac catheterization laboratory. Typically, t he device is inserted via the femoral artery; however, in some circumstances, it can be placed via a chimney gra sewn to the axillary artery. e device is placed such that it spans the aortic valve, with the inlet portion positioned in the LV cavity and the outlet portion in the aortic root (Fig. 56.5). e Impella® pump is available in several dierent congurations, the most important of which are the 2.5 and 5.0 models. e Impella® 2.5 is capable of providing temporary support, and is typically used for support during high- risk PCI. As its name suggests, it can provide up to 2.5 L of support at maximum speed. e Impella® 5.0 is capable of providing up to 5 L of support at a maximum speed of 33,000 rpm. It is oen used for short- term support for a failing heart. Additionally, a right heartspecic Impella® has recently been approved for use, the Impella® RP. e device is designed to be placed such that its inlet region is in the inferior vena cava and its outlet is distal to the pulmonic valve. e device is capable of providing circulatory assistance for up to 14days for patients experiencing acute right heart failure.

Fig.56.5 (a) The Impella

(b)The Impella® device alone.

device positioned within the left ventricle.

e Impella® device has been successfully deployed prophylactically in patients undergoing high- risk PCI as a means to prevent or manage periprocedural decreases in cardiac function. When compared to IABP, high- risk patients undergoing PCI supported with the Impella® device experienced similar rates of 30- day major adverse events. ere was, however, a non- statistically signicant trend towards improved outcomes in patients treated with the Impella® device. Despite the absence of conclusive evidence to support its use, placement of an Impella® prior to high- risk PCI has become commonplace at many institutions.

In addition to haemodynamic support during high- risk PCI, there is a potential role for the Impella® device as an adjunct during CABG. Meyns etal. reported preliminary results of microaxial pumps used for patients undergoing CABG. However, when compared to traditional on- pump CABG, Impella®- supported CABG demonstrated no dierence in clinical outcome, number of gras performed, or adverse events.

Recently, the impact of LV unloading on ongoing AMI in an animal model showed that reducing LV workload and volume over a prolonged period may reduce the area of myocardial infarction and related functional damage. is eect is well- known in cardiac surgery where patients with haemodynamic diculty during weaning from CPB benet from temporary LV unloading and circulatory support. is concept might pave the way to broader and innovative application of percutaneous unloading/ supportive devices including CABG patients with acute ischaemic injury and its related consequences. Specic and relevant investigations about the potential impact of an Impella® device or other temporary percutaneous assist devices are, however, not available. Further clinical studies are, therefore, warranted to quantify the ecacy of these various systems in the post- cardiotomy setting.

Long- lasting mechanical support (implantable or paracorporeal)

e Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) has clearly demonstrated lower survival in patients with INTERMACS level 1 (critical CS). While some studies advocate direct VAD implantation in the setting of CS, an overall slight decrease in the proportion of INTERMACS level 1 patients has been demonstrated in recent years., Generally, patients are stabilized with less invasive temporary VAD therapy in an attempt to adjust their INTERMACS prole. If cardiac function cannot be appropriately supported, then escalating MCS should be instituted early. Alternatively, patients with a history of heart failure (acute- on- chronic myocardial ischaemia) and those with nongraable coronary arteries, or complex operations may benet from a primary VAD placement instead of CABG in the setting of CS. Although only a handful of case reports and cohort studies support this option, short- term VAD stabilization should remain as the primary supportive therapy. us, a patient- tailored approach given various clinical scenarios, availability of MCS, and surgeon experience is required for satisfactory outcomes. e transition to more technologically advanced assist devices is likely and indeed, in the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support erapy With HeartMate 3 (MOMENTUM 3), the use of a fully magnetically levitated centrifugal- ow le VAD was shown to positively impact mediumterm morbidity freedom as compared to older axial ow pumps.

56 Management and impact of cardiogenic shock/cardiac arrest 395

%Survival

Non-CABG CABG

https://t.me/medicina_free

1.0

0.8

0.6

0.4

0.2

0.0

5 10 15

Days

P = 0.014

20 25

94.1%

75.0%

Fig.56.6 Early survival rates in patients undergoing isolated left VAD

(51 patients) or left VAD implantation associated with CABG surgery (28 patients). The two groups were comparable in terms of age, sex, and device implantation.

Reproduced from Mehta P, Imamura T, Juricek C, Sarswat N, Kim G, Raikhelkar J, Song T, Ota T, Jeevanandam V, Sayer G, Uriel N.Combined left ventricular assist device and coronary artery bypass grafting surgery:should we bypass the bypass? ASAIO J 2019 with permission from Wolters Kluwer.

Notwithstanding, CABG with concomitant le VAD implantation has been shown to signicantly increase early mortality (75% vs 94.1% at 30days) and not provide any benet in terms of perioperative morbidity (Fig. 56.6). It seems, therefore, advisable to indicate such a combined approach only in very selected cases, taking into account the higher risk of unfavourable early outcomes.

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30.08.202671 Мб0Книга_3619_Библиотеки_им_академика_М_И_Перельмана.pdf