Update on the Treatment of

Cardiogenic Shock in Acute MI

Daniel Burkhoff MD PhD
Adjunct Associate Professor of Medicine
Columbia University

Disclosures: Employee of HeartWare; Educational Grant Abiomed

Faculty Disclosure
Company

Nature of Affiliation

Unlabeled Product
Usage

HeartWare

Employee

None

Abiomed

Educational Grant

None

Thirty-Year Trends (1975 to 2005) in the Magnitude of,

Management of, and Hospital Death Rates Associated
With Cardiogenic Shock in Patients With Acute
Myocardial Infarction

Percent AMI with CGS

Goldberg et al, Circulation 2009;119:1211-1219

Copyright American Heart Association, Inc. All rights reserved.

Thirty-Year Trends (1975 to 2005) in the Magnitude of,

Management of, and Hospital Death Rates Associated
With Cardiogenic Shock in Patients With Acute
Myocardial Infarction

Mortality (%)

Goldberg et al, Circulation 2009;119:1211-1219

Copyright American Heart Association, Inc. All rights reserved.

In-hospital Mortality + Treatment

Trends
80

80

PCI (p<0.01)

70

Thrombolysis (p<0.01)

70

IABP (p<0.01)

60

CABG

60
50

50

% 40

% 40

30

30

20

20

Cardiogenic Shock (Total)

Cardiogenic Shock at admission (p=0.009)

10

Cardiogenic after admission (p=0.094)

10
0

0
1997

1999

2001

2003

2005

1997

1999

Jeger et al. Ann Int Med 2008;149:618-626

2001

2003

2005

EARLY REVASCULARIZATION IN ACUTE MYOCARDIAL INFARCTION

COMPLICATED BY CARDIOGENIC SHOCK
Hochman et al, NEJM 1999;341

SHOCK Trial
Proportion Alive

1.0

30 days

Log-Rank p = .024

0.8
0.6

ERV (N=152)
0.4
0.2

IMS (N=150)
0.0
0

Years From Randomization

Hochman J. JAMA 2001; 285: 190-192

Estimated In-Hospital
Mortality (%)

CPO and Survival in CGS/AMI

Cardiac Power Output (Watts)

Fincke et al. (JACC 2004)

Meta-analysis of Percutaneous LVAD in CGS

Table 1. Study characteristics of included trials

Percutaneous LVAD used

Control
Total number of patients
Setting
Randomization
Sequence generation

Thiele

Burkhoff

Seyfarth

et al.

et al.

et al.

TandemHeart

TandemHeart

Impella LP25

IABP

IABP

IABP

41

33

26

Single-centre

Multi-centre

Two-centre

Yes

Yes

Yes

Drawing

Not reported

Not reported

Sealed envelopes

Not reported

Not reported

Not possible

Not possible

Not possible

Complete follow-up

Complete follow-up

Complete follow-up

Envelopes
Concealment of
allocation
Blinding
Handling of
patient attrition

* Not reported whether the envelopes were opaque and sequentially numbered.
IABP, intra-aortic balloon pump; LVAD, left ventricular assist device.

Cheng et al, European Heart Journal

2009;30:2102-2108

Hemodynamics
LVAD
IABP
Cardiac index
Mean + SD Mean + SD Mean Difference

P(heterogeneity) = 0.22
l2 = 34.0%

Thiele et al.
Burkoff et al.

2.3 + 0.6

1.8 + 0.4

0.55 (0.23-0.87)

2.2 + 0.6

2.1 + 0.2

0.16 (-0.14-0.46)

Seyfarth et al.

2.2 + 0.6

1.8 + 0.7

0.35 (-0.16-0.88)

Pooled

0.35 (0.09-0.61)
-2

Thiele et al.

-1
Favors IABP

1
Favors LVAD

LVAD
IABP Mean Arterial Pressure
Mean + SD Mean + SD Mean Difference
76 + 10
70 + 16

P(heterogeneity) = 0.10
l2 = 55.9%
0.55 (-2.9-13.9)

Burkoff et al.

91 + 16

72 + 12

18.6 (9.4-27.9)

Seyfarth et al.

87 + 18

71 + 22

16.0 (0.5-31.5)
12.8 (3.6-22.0)

Pooled
-50

-25
Favors IABP

25
Favors LVAD

50

LVAD
IABP Pulmonary wedge pressure P(heterogeneity) = 0.01
Mean + SD Mean + SD
Mean Difference
l2 = 76.6%
Thiele et al.

16 + 5

22 + 7

-5.6 (-9.2 to -2.1)

Burkoff et al.

16 + 4

25 + 3

-8.4 (-11.0 to -5.8)

Seyfarth et al.

19 + 5

20 + 6

-1.0 (-5.2-3.2)
-5.3 (-9.4 to -1.2)

Pooled
-20

-10
Favors LVAD

10
Favors IABP

Cheng et al, European Heart Journal

2009;30:2102-2108

20

30 Day Mortality
LVAD
n/N

IABP
n/N

30-day Mortality
Relative Risk

P(heterogeneity) = 0.83
l2 = 0%

Thiele et al.

9/21

9/20

0.95 (0.48-1.90)

Burkhoff et al.

9/19

5/14

1.33 (0.57-3.10)

Seyfarth et al.

6/13

6/13

1.00 (0.44-2.29)

24/53

20/47

1.06 (0.68-1.66)

Pooled

0.1

1
Favors LVAD

10
Favors IABP

Cheng et al, European Heart Journal

2009;30:2102-2108

Randomized Studies in Cardiogenic Shock

Trial

Follow-up

n/N

Revascularization (PCI/CABG)
SHOCK
SMASH
Total

1-year
30 days

76/152
22/32
103/184

Relative Risk
95% CI

n/N

0.80 (0.66;0.98)
0.87 (0.66;1.29)
0.82 (0.70;0.98)

83/149
18/23
117/172
Early revascularization
better

Catecholamines
SOAP II (CS Subgroup)

28 days

64/145

NO Synthase Inhibitors
TRIUMPH
SHOCK-2
Cotter et al
Total
IABP
IABP-SHOCK I
LVAD
Thiele et al
Burkhoff et al
Seyfarth et al
Total

In-hospital

15/40

0.75 (0.55;0.93)

97/201
24/59
4/15
125/275

1.15 (0.59;2.27)

7/19

1.14 (0.91;1.45)
1.16 (0.59;2.69)
0.40 (0.13;1.05)
1.05 (0.85;1.29)

9/21
9/19
6/13
24/53

Placebo
better

6/21

1.28 (0.45;3.72)
IABP
better

30 days
30 days
30 days

Standard treatment
better

76/180
7/20
10/15
93/215
NO Synthase inhibition
better

30 days

Dopamine
better

13/40
Up-stream Abciximab
better

30 days
30 days
30 days

Medical treatment
better

50/135
Norepinephrine
better

Glycoprotein IIb/IIIa-Inhibitors
PRAGUE-7

Relative Risk
95% CI

9/20
5/14
6/13
20/47
LVAD
better

Standard treatment
better

IABP
better

0 0.25 0.5 0.75 1 1.5 2 2.5 3

Thiele et al. Eur Heart J 2010,31:1828-1835

0.95 (0.48;1.90)
1.33 (0.57-3.10)
1.00 (0.44-2.29)
1.06 (0.68-1.66)

IABP-Shock-II Trial
DSMB:

Kurt Huber
Ferenc Follath
Bernhard Maisch
Johannes Haerting
Steering committee:

Holger Thiele
Karl Werdan
Uwe Zeymer
Gerhard Schuler
Support +
Patronage:

IABP Shock-II
Primary Study Endpoint (30-Day Mortality)
50

Mortality (%)

Control

41.3%
39.7%

40
IABP
30

20

P=0.92 by log-rank test

Relative risk 0.96; 95% CI 0.79-1.17; P=0.69 by Chi2-Test

10

0
0

10

15

20

25

Time after Randomization (Days)

Thiele et al. NEJM 2012;367:1287-1296

30

IABP Shock-II
Primary Study Endpoint (30-Day Mortality)

Thiele et al, Lancet, Volume 382, Issue 9905, 2013, 1638 - 1645

16

EU and US Guideline Recommendations

Assist ESC/EACTS [1, 2]
device
Cardiogenic IABP
Class IIb (B) Intra-aortic balloon
pumping may be
shock
considered.
Indication

Other Class IIb (C) LV assist devices may

be considered for
devices
circulatory support in
patients in refractory
shock.

ACCF/AHA/SCAI [3-6]
Class IIa [B]

Class IIb [C]

The use of intra-aortic

balloon pump (IABP)
counterpulsation can be
useful for patients with
cardiogenic shock after
STEMI who do not quickly
stabilize with
pharmacological therapy.
Alternative LV assist devices
for circulatory support may
be considered in patients
with refractory cardiogenic
shock.

Burkhoff et al. Chapter 27: Percutaneous Circulatory Support: Intra-aortic Balloon

Counterpulsation, Impella, TandemHeart, and Extracorporeal Bypass
In: Baim & Grossmans Cardiac Catheterization, Angiography, and Intervention,, 8th
Edition, Editor: Mauro Moscucci

Review and Comparison of

Cardiac Support Strategies
Strategy

Therapy /
Device

Mechanism

Medical Management

Inotropes /
Pressors

Increase Contractility, HR,

TPR

IABP

Aortic Pressure
Augmentation

Counterpulsation

Extracorporeal Bypass TandemHeart

Pump
ECMO
Implantable
Transvalvular Pump

Impella
2.5/4.0/5.0

LA -> AO flow
RA -> AO flow
LV -> AO flow

17

Pressure-Volume Loops and Relationships

LV Pressure (mmHg)

150
125
100
75
50
25
0

25

50

75

100

125

LV Volume (ml)

150

18

19

Contractility
Ees

Ees

LV Pressure (mmHg)

150
125
100
75
50
25
0

50

100

LV Volume (ml)

150

Left Ventricular Pressure

Cardiac Power Output (CPO)

20

CPO = SW*HR
MAP*SV*HR

SW

Left Ventricular Volume

Left Ventricular Pressure

Determinants of
Myocardial Oxygen Consumption

PVA = PE+SW
Heart Rate
SW
PE
Left Ventricular Volume

Contractility

21

Balance between Energy Supply and Demand and its

Impact on Myocardial and Vascular Properties

23

Hemodynamic principles
provide important insights into
different forms of mechanical
circulatory support (MCS) in
various clinical settings

24

A Typical Case of CGS in AMI

59 year old man, multiple cardiac risk factors
NSTEMI, EF 15%
Cath: Diffuse disease in LCx and LAD
100% RCA with diffuse disease
Hemodynamics:
HR: 122
CVP: 11
PAP: 37/29 (31)
PCWP: 22
AoP: 75/53 (62)
CO/CI: 3.2/1.8
CPO: 0.44 Watts

25

Harvi

Interactive, simulation-based
textbook for the iPad
(for iPad 2, 3, mini)

26

ECMO vs Direct LV Unloading

ECMO
Provides effective cardiac support, especially in the
setting of RV failure
Improved systemic oxygenation
CAUTION: LV can be overloaded and pulmonary
edema can be exacerbated

Transvalvular Percutaneous LVAD

Improves systemic hemodynamics
Unloads the LV
Oxygenation can be improved secondary to
reduced PCWP

Conclusions: CGS in AMI

There is no unequivocal benefit to LV support in
CGS
IABP is clearly not the answer (though may be
useful to increase coronary flow with no reflow or
residual stenosis)
LVAD support makes most sense upfront in
hypotensive patients for PCI to support the
procedure and allow decisions for possible
bridging
ECMO is best for total crash and burns