Abstract of medical PHD thesis: Study on the hemodynamic effect of intra-aortic balloon pump counterpulsation (IABP) therapy in patients with cardiogenic shock after myocardial infarction

The new conclusions of this study: Efficacy of intra-aortic balloon pump counterpulsation (IABP) in hemodynamic support to patients with cardiogenic shock after myocardial infarction. Remarks on the efficacy of treatment and complication of intra-aortic balloon pump counterpulsation (IABP) in the treatment of cardiogenic shock after myocardial infarction

MINISTRY OF EDUCATION & TRAINING MINISTRY OF DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND

PHARMACEUTICAL SCIENCES -

NGUYEN MANH DUNG

STUDY ON THE HEMODYNAMIC EFFECT OF AORTIC BALLOON PUMP COUNTERPULSATION THERAPY IN PATIENTS WITH CARDIOGENIC SHOCK

INTRA-AFTER MYOCARDIAL INFARCTION

Specialty: Anesthesia and Critical Care

Code: 62.72.01.22

ABSTRACT OF MEDICAL PHD THESIS

Hanoi – 2019

THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

Supervisor:

1 Assoc Prof PhD Tran Duy Anh

2 Assoc Prof PhD Le Thi Viet Hoa

Day Month Year

The thesis can be found at:

1 National Library of Vietnam

2 Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences

INTRODUCTION

Cardiogenic shock (CS) is a condition of reduced tissue perfusion, due to impairment of the pumping function of ventricles under normal circulation volume In patients with myocardial infarction, cardiogenic shock was the highest mortality rate, the previous mortality rate was 80%, thanks to improvements in emergency and treatment, mortality rates were reduced to 40-50%

Active treatment to restore, maintain hemodynamic stability, ensure optimal blood oxidation and coronary revascularization was the main treatment for patients with cardiogenic shock after myocardial infarction The emergence of mechanical support facilities such as intra-aortic balloon pump counterpulsation (IABP), left ventricular support, ECMO contribute to increasing the quality of cardiogenic shock treatment

IABP is a device that supports mechanical circulation, is placed through the femoral artery by Seldinger technique, the balloon is inflated

in the diastole (increased coronary artery perfusion, cerebral vessels), is rapidly flushed in the systole (reduced heart activity, reduced the need for

02 cardiac muscles and increased cardiac output) In 1968, IABP technique was first used for patients with cardiogenic shock after myocardial infarction, with 70,000 - 100,000 cases in the United States every year

In Vietnam, IABP has been used in some hospitals, such as: Ho Chi Minh City Heart hospital (2005), 108 Military Central Hospital (2009), Hanoi Heart hospital (2012) has brought good effects on patients with severe heart failure after open heart surgery, cardiogenic shock

In order to assess the effectiveness and safety of intra-aortic balloon pump counterpulsation (IABP) in hemodynamic support to patients with cardiogenic shock due to myocardial infarction, we

conducted the study"Study on the hemodynamic effect of intra-aortic balloon pump counterpulsation (IABP) therapy in patients with cardiogenic shock after myocardial infarction”with two objectives:

1 Efficacy of intra-aortic balloon pump counterpulsation (IABP) in hemodynamic support to patients with cardiogenic shock after myocardial infarction

2 Remarks on the efficacy of treatment and complication of intra-aortic balloon pump counterpulsation (IABP) in the treatment of cardiogenic shock after myocardial infarction

Chapter 1 OVERVIEW

1 Cardiogenic shock after myocardial infarction

1.1 Definition and diagnosis of cardiogenic shock after myocardial infarction

* Definition of cardiogenic shock

Cardiogenic shock is defined as tissue hypoperfusion resulting from ventricular pump failure in the presence of adequate intravascular volume

1.2 Causes and pathogenesis of cardiogenic shock

1.2.1 Causes of cardiogenic shock

Cardiogenic shock may occur acute in patients without a previous history of heart disease or progressive disease progression in patients with persistent chronic heart failure, most commonly acute coronary syndrome: 80% Although advances in treatment and revascularization, cardiogenic shock remains the most dangerous complication of myocardial infarction with a mortality rate of about 38% to 65% Cardiogenic shock after myocardial infarction is most commonly caused by ischemic heart muscle dysfunction, infarction

or mechanical complications

1.2.2 Pathogenesis

Acute myocardial ischemia due to coronary arteries reduces the function of myocardial contractility and the ejection capacity of the ventricles and increasing the final filling pressure Decreased systolic function leads to reduced cardiac output, arterial hypotension, reduced perfusion and reduced systemic oxygen supply Systemic inflammatory response causes systemic vasodilation, inhibits myocardial contraction causing severe progressive shock

Figure 1.1 Pathogenesis of cardiogenic shock after myocardial infarction

1.2.3 Hemodynamics of cardiogenic shock after myocardial infarction

Pathophysiology of cardiogenic shock, illustrated by pressure-volume loop ESPVR goes down and to the right, there is a sudden loss of contraction, severe decrease in blood pressure, volume of squeeze and heart supply Neural-activated receptors automatically reach the heart, vascular structures, and activate the adrenal gland to release epinephrine These factors increase heart rate, increase heart contraction and cause systemic vasoconstriction, increase SVR and cause vasoconstriction - making changes to the left side of the P-V loop(Figure 1.3)

Figure 1.3 The pathophysiology of CS illustrated by use of PV loops

1.2.4 Treatment of cardiogenic shock after myocardial infarction

Treatment of cardiogenic shock is an emergency procedure, requiring intensive resuscitation to ensure optimal blood oxidation and hemodynamic stability to facilitate early reperfusion therapy, or restore myocardial function after reperfusion

Intensive care unit treatment

The basic treatment measures include initial stabilization with volume expansion to obtain euvolaemia, vasopressors, and inotropes plus additional therapy for the prevention or treatment of multiorgan system dysfunction (MODS) Norepinephrine is a vasopressor should be the first choice, dobutamin can be combined with norepinephrine to improve myocardial contractility Early revascularization is an important treatment strategy, mechanical devices are increasingly interested in research and application in the treatment of CS

Table 1.2 Schematic drawings of current percutaneous

mechanical support devices for CS

2 Principles of intra-aortic balloon pump counterpulsation 2.1 Basic principles of counterpulsation

IABP is a device to support mechanical circulation, placed through the femoral artery into the aorta by Seldinger technique; The balloon

is inflated in the diastole (increased coronary artery perfusion, cerebral vascular) and rapid flushing in systole (reducing heart activity, reducing the need for 02 heart muscle and increasing cardiac output)

Figure 1.5 The principle of operation of IABP

2.2 2 Indications and contraindications of IABP

*Indications

- Cardiogenic shock after myocardial infarction, or myocarditis, cardiomyopathy

- Ventricular arrhythmias cannot be treated with drugs

- Unstable angina refractory to drug treatment is an indication for IABP

- Heart failure does not respond to medical treatment

- Prophylactic support in preparation for cardiac surgery

- Low cardiac output after cardiopulmonary bypass

- Mechanical bridge to other assist devices

* Contraindications

- Absolute: Severe aortic valve opening, aortic dissection

- Relative: severe vascular disease, severe injury, severe hemorrhage

2.3 IABP for the treatment of cardiogenic shock after myocardial infarction

2.3.1 Physiological effects of IABP therapy

Inflated balloon makes blood movement, increases coronary blood flow through diastolic pressure and diastolic pressure difference Thanks to diastolic hypertension and decreased systolic blood pressure, IABP reduces the left ventricular postpartum load, reduces left ventricular wall strain and reduces the demand for myocardial oxygen consumption

Figure 1.6 Effect of the IABP on the ratio of oxygen supply and demand DPTI/ TTI

IABP and consumption - supply oxygen for myocardial: IABP improves myocardial oxygen supply - increases EVR, evaluated by

the diastolic pressure tension index (DPTI) and time index tension (TTI) (Figure 1.9)

EVR = DPTI = SUPPLY OF OXYGEN

DPTI/ TI is the ratio of myocardial oxygen supply (EVR), EVR

<0.7: myocardial ischemic

2.3.2 Complications of IABP

Vascular complications: bleeding, thrombosis, anemia The most common vascular complications are limb ischemia, with 14 - 45% patients treatment ofIABP

3 Some studies on the treatment of cardiogenic shock after myocardial infarction

3.1 Studies from worldwide

Research on cardiogenic shock after MI is divided into 2 stages:

*Stage before reperfusion treatment

During this period, the main treatment method was to maintain hemodynamics with vasopressor drugs and to begin the study to apply IABP In 1934, Fishberg et al described the first clinical case of cardiogenic shock after acute myocardial infarction In 1954, Griffith first used Noradrenaline to raise blood pressure in cardiogenic shock In

1968, Kantrowitz applied IABP to maintain hemodynamics for cardiogenic shock

* The stage of reperfusion treatments were performed

During this period, treatments for reperfusion were established such as CABG, fibrinolytic and PTCA with advances in resuscitation such as ventilation, dialysis focusing on assessing the effectiveness of reperfusion treatment, the use of IABP and a number of mechanical hemodynamic support devices

In 1980, Mathey injected Streptokinase into coronary arteries for patients with cardiogenic shock Percutaneous coronary angioplasty for patients with MI due to MI was applied by Meyer in 1982 In 2003, Cotter G, demonstrated the effect of synthetic inhibitor NO Studies include Jinteren Cardio 1991, The Shock Trial registry JACC 2000, Cheng 2009 showed: IABP improves prognosis and survival rate in cardiogenic shock

3.2 In Viet Nam

The rate of cardiogenic shock by Do Kim Bang in 2002 was 11.4%, Nguyen Quang Tuan in 2005, the rate of cardiogenic shock was 17.4% with a mortality rate of 40% Hoang Minh Viet's research shows that the overall mortality rate is 60%, the group with coronary angioplasty is lower than the non-coronary group (47.4% vs 69.2%), 42.2% patients died in the first week

3.3 The issues that need to be researched on IABP

Although there have been many studies on IABP, but there are limitations: do not describe the time since the patient was shocked until the ball was placed and applied other treatments, so there is not enough grounds to concludethe effectiveness of the IABP with respect to the final outcome, does not describe the degree of hemodynamic improvement immediately after placing the balloon - This is a bridge to apply coronary revascularization measures Therefore, the study evaluated the efficacy and safety of IABP in the treatment of cardiogenic shock after myocardial infarction is the necessary research direction

Chapter 2 SUBJECTS AND METHODS 2.1 Studying subjects

2.1.1 Place, time

- Place: 108 Military Central Hospital and Hanoi Heart Hospital

- Time: 2012 – 2017

2.1.2 Selection criteria for study patients

Cardiogenic shock after myocardial infarction patients treated by IABP

a Diagnostic criteria myocardial infarction

Diagnosis of MI according to ESC/ACCF/AHA/WHF2012

b Diagnostic criteria cardiogenic shock

* SBP less than 90 mm Hg for greater than 30 minutes including at least one of the following:

- Change of consciousness, irritation or coma

- Spasm of peripheral vessels, cold limbs

* Hemodynamic exploration parameters:

Cardiac index (CI) below 2.0 l/min/m2 of skin when no cardiac support is used or less than 2.2 l/min/m2 of skin when cardiac support is used

- Circulatory stop due to other causes

2.2 Research methodology

2.2.1 Research design:prospective, interventional Number of patients: 45 2.2.2 Research devices

- Modern cardiovascular intervention system

- Multi-functional hemodynamic monitoring system

- Blood gas mechine,color ultrasound, electric shock machine

- Continuous dialysis machine, Cardiopulmonary X-ray machine in bed -IABP pump system – Datascope CS 300 of USA

- Types of IABP

2.2.3 Study procedure

2.2.3.1 The information of patients was collected

- General information: Age, gender, occupation, history of disease, etiology, time of starting chest pain until hospital admission, time of shock appearance

- Assess the severity of hospitalization and treatment

- Put central venous catheter, arterial pressure measurement line

-Cardiac enzyme, arterial blood gas

-ECG, cardiopulmonary X-ray, coronary angiography

-Echocardiography: EF%, SV, SVR, CO, CI, mechanical complications

2.2.3.2.Intensive care unit treatment

Active treatment according to the Ministry of Health's general regimen, maintaining circulation volume, CVP 10-14; maintain systolic BP> 90 mmHg

* Fluids, vasopressors, inotropes

2.2.3.3.IABP support

a Balloon Pump and Equiment

Datascope CS 300 machine of the US and other types of balloon pump counterpulsations

b Balloon catheters /sizing

- Ball length: under the left subclavian artery and above the renal artery

- Choose the ball according to the height of the patient:

- Height <152 cm 25 cc ball

- Height 152 - 163 cm  34 cc ball

- Height 163 - 183 cm  40 cc ball

- Height> 183 cm  50 cc ball

c Methods of insectionIntra- Aortic balloon catheter

Place the ball by Seldinger technique through the femoral artery, close to the left subclavian artery 2cm,the proximal balloon end should be lying above the renal vessels.Ball position is checked by ultrasound and X ray

d Timing and follow-up after placingIABP

- Signal source: ECG or arterial pressure chart

- Follow-up: Parameters of the machine, hemodynamic indicators; the ball set, color and temperature of the lower limb

e Clinical Issues

- Clinical:

Improving MAP (desired level of 70 - 80 mmHg)

Reduced heart rate (Heart rate decreased by 15-20% compared to cardiogenic shock)

Improve kidney function (urine> 60ml/h)

- Pressure criteria: Difference between unsupported systolic blood

pressure and "increased diastolic blood pressure": 10 mmHg

-Weaning and removal balloon process:

+ When hemodynamics improves well and is stable

+ Dose of dobutamine <8, epinephrine <0.4; norepinephrine <0.4 + Reduce support rate from 1: 1 to 1: 2, 1: 3 (4 hours), reduce ball volume

- Removal

2.2.2.5 Echocardiography assesses left ventricular function

3 Research content and evaluation criteria

3.1 General characteristics of the research object

3.2 Efficacy of intra-aortic balloon pump counterpulsation (IABP) in hemodynamic support to patients with cardiogenic shock after myocardial infarction

3.3 Efficacy of treatment and complication of intra-aortic balloon pump counterpulsation (IABP) in the treatment of cardiogenic shock after myocardial infarction

4 Time of evaluation: Hospitalization (T0), after placing the ball for 1

hours (T1), after 3 hours (T3), after 6 hours (T6), after 24 hours (T24), after the fourth day of the year 4, 6 , 7 (D4, D5, D6, D7) and when

withdrawing the ball

CHAPTER 3

RESULTS 3.1.General characteristics of research patients

Table 3.1 Age, gender of study subjects

Age (years) 69,11 ± 10,94 (41 - 88)

Comment: There were 45 patients included in the study The percentage

of female was 40% The average of age was 69,11 ± 10,94years

Table 3.2 Historical and risk factors

Comment: There was 64.4% patients with angina pectoris, 48.8% with

hypertension, 26.6% smokers; 35.5% patients with acute kidney disease; 22.2% diabetes; 6.6% COPD; Peripheral vascular disease (6,67%)

Table 3.3 Cardiovascular characters

Stenosis of three coronary arteries 30 (66.7)