Navin K. Kapur, MD, FACC, FSCAI, FAHA

Associate Professor, Department of Medicine

Interventional Cardiology & Advanced Heart Failure Programs

Executive Director, The Cardiovascular Center for Research & Innovation

Shock is the New STEMIFuture Directions in Cardiogenic Shock

Relevant Disclosures

Research Funding & Speaker/Consulting Honoraria:

Abiomed, Abbott, Boston Scientific, Maquet, Medtronic, MD Start, Cardiac Assist

Herbert J. Levine

Foundation

Tufts Medical Center

RO1HL139785, RO1H133215

Charlton Award

Tufts Medical Center

Triage and Transfer for STEMI

The Hub and Spoke Model

Triage and Transfer for Cardiogenic Shock

The Hub and Spoke Model

AHA Consensus Statement 2017

ECG = STEMI PAC = SHOCK

Rapid, Available, and High Yield Diagnostic Tools

From Drugs to Devices in STEMI and Shock

Drug Device

Drug Device

Tufts Cardiogenic Shock Algorithm

Hemodynamically driven decision making

Kapur et al. Curr Cardiol. 2016

Change 1: Pheno-profiling Cardiogenic Shock

1010 Cases

CP + RP

IABP only

Impella 5.0

Impella 5.0 + RP

Impella CP

Impella RP

No AMCS

Other

VA ECMO

VA ECMO + Impella CP

176, 22%

178, 22%

145, 18%

16, 2%

24, 3%

5, 1%

2, <1%

162, 20%

83, 10%

27, 3%

Impella VA-ECMO 0

20

40

60

80

100

Pulmonary Artery Catheter Pre-AMCSM

ort

ality

(%

)

No

Yes

p<0.001

A B

C D

<9 9-12 13-17 ≥180

20

40

60

Right Atrial Pressure (mmHg)

Mo

rtality

(%

)

*

*

†

†‡

142 120 136 178

*, p<0.05: Compared to RAP <9 mmHg†, p<0.05: Compared to RAP 9-12 mmHg‡, p<0.05: Compared to RAP 13-17 mmHg

<9 9-12 13-17 ≥180

20

40

60

Right Atrial Pressure (mmHg)

Mo

rtality

(%

)

*

*

†

†‡

142 120 136 178

*, p<0.05: Compared to RAP <9 mmHg†, p<0.05: Compared to RAP 9-12 mmHg‡, p<0.05: Compared to RAP 13-17 mmHg

NonCongested

LV RV BIV0

20

40

60

80

100

Mo

rtality

(%

)

103 189 34 246

* †* †

*, p<0.05: Compared to Non-congested†, p<0.05: Compared to LV-dominant

Let the Hemodynamics Guide Your Decision Making

Morine & Kapur et al. Shock Working Group

Courtesy of D. Burkhoff Kapur Lab

Change 2: LV Unloading as a Therapy not Simply an

Adjunctive Intervention for Support

Lija Swain : Kapur Lab 2018

Ingenuity Pathway Analysis

Mitochondrial Dysfunction

Oxidative Phosphorylation

Sirtuin Signaling Pathway

TCA Cell Cycle

Fatty Acid b-oxidation

Beta-adrenergic signaling

Change 2: LV Unloading as a Therapy not Simply an

Adjunctive Intervention for Support

An Integrated View of AMI and Shock Biology

C

Kapur Lab

Ventricular Load Impacts Myocardial Recovery

O’Neill W. JIC 2013

Change 2: LV Unloading as a Therapy not Simply an

Adjunctive Intervention for Support

Tufts Cardiogenic Shock Algorithm

Hemodynamically driven decision making

Biventricular Congestion in Shock is

Common and Deadly

NonCongested

LV RV BIV0

20

40

60

80

100

Mo

rtality

(%

)

13/98 32/180 14/32 99/235

* †* †

Cardiogenic Shock Working Group

0 10 20 30 400

20

40

60

80

RAP (mmHg)

PC

WP

(m

mH

g)

Total Congestive Profiles Scatterplot

Non-Survivor

Survivor

14

18

Change 3: Unloading and Decongestion

<9 9-12 13-17 ≥180

10

20

30

40

50

Right Atrial Pressure (mmHg)

Mo

rtality

(%

)

*

*

†

†‡

134 113 130 168

<9 9-12 13-17 ≥180.0

0.5

1.0

1.5

2.0

2.5

Right Atrial Pressure (mmHg)S

eru

m C

reati

nin

e (

mg

/dl)

p<0.001

Right Atrial Pressure is a common denominator for poor outcomes

Tufts Cardiogenic Shock Algorithm

Hemodynamically driven decision makingVenous Congestion Drives Mortality and Morbidity

Cardiogenic Shock Working Group

Tufts Cardiogenic Shock Algorithm

Hemodynamically driven decision makingRecognizing the Cardio-Renal Axis in Shock

Patel and Bezerra et al ASAIO 2018

Change 4: Optimizing ECMO Venting Strategies

Superior Outcomes with EcPella vs ECMO

Antegrade Perfusion6Fr Braided Sheath

Impella CP 14Fr Sheath

PA Catheter 8Fr Cordis

17Fr Arterial Cannula25Fr MS Venous Cannula

Antegrade Perfusion6Fr Braided Sheath

High Pressure 3-Way + 2 Male-to-Male

Connectors

Change 5: Increasing Focus on Vascular

Outcomes (Deployment and Removal)

2 x 035 wires through7/14Fr telescoping sheath

RemovingCP & Repo Sheath

Side-arm stylet removedCath Lab – sterile prepAntibiotics on board

Sheaths out. 7Fr buddy dilatorPerclose Number 1 at 10:00 Dry Bed with Perclose 1 Hemostasis with 2 Perclose

devices and 10 minute hold

Change 5: Increasing Focus on Vascular

Outcomes (Deployment and Removal)

From Door to Support to Door to Unload

Percutaneous Left Atrial Decompression Reduces LV

Wall Stress and Reduces Infarct Size

Kapur NK et al Circulation 2013

Introduced a 30 minute delay to reperfusion

after LV Unloading

Kapur NK et al JACC HF 2015

Primary Unloading : Impella Micro-Axial Pump

Reperfusion Unloading Reperfusion Unloading0

5

10

15

20

% S

car

by L

GE

or

An

ato

mic

Path

olo

gy

LGE by CMR Anatomic Pathology

p = 0.03 p = 0.02

Primary Unloading Reduces LV Scar and Preserves Cardiac

Output 30 days after Acute MI

Esposito, Zhang, Qiao and Kapur et al JACC 2018

Heart Attack (no pump)

Heart Attack (+ Pump)

Reperfusion

Alone15 min 30 min Unloading After

ReperfusionUnloading Before

Reperfusion

Unloading First & Delaying Reperfusion

Maximally Reduces Infarct Size (Preclinical)

*

JACC 2018

DTU-Pilot

DTU-Pivotal

Door To Unload: STEMI Safety & Feasibility Trial

Informed Consent

Enrollment and Randomization

Explant Impella CP after a minimum of 3 hours support

INCLUSION CRITERIA• Age 21-80 years• First Myocardial Infarction• Acute STEMI (anterior ST elevation ≥2 mm in ≥2 contiguous or ≥4 mm ST-sum)• Within 1 to 6 hours of symptom onset

Anterior STEMI Referred for Primary PCI

Impella CP Insertion + Activation

LV Unloading, Then Immediate PCI Reperfusion

(U-IR Group)

LV Unloading for 30 minutes,Then Delayed Reperfusion

(U-DR Group)

ENROLLMENT COMPLETED

May 2018

Late Breaking Presentation at

AHA 2018 – Chicago – Nov 2018

Thank you

nkapur@tuftsmedicalcenter.org

Shock is the New STEMIFuture Directions in Cardiogenic Shock