MINISTRY OF EDUCATION & TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES - NGUYEN MANH DUNG STUDY ON THE HEMODYNAMIC EFFECT OF INTRAAORTIC BALLOON PUMP COUNTERPULSATION THERAPY IN PATIENTS WITH CARDIOGENIC SHOCK 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: Assoc Prof PhD Tran Duy Anh Assoc Prof PhD Le Thi Viet Hoa Reviewer: This thesis will be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year The thesis can be found at: National Library of Vietnam 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 intraaortic 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: 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 Chapter OVERVIEW 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 * Diagnosis of cardiogenic: - SBP less than 90 mm Hg for greater than 30 minutes or use of vasopressors to achieve those levels.Evidence of pulmonary edema or elevated left ventricle (LV) filling pressures (LV end diastolic pressure or PCWP) - Evidence of organ hypoperfusion including at least one of the following: (a) change in mental status; (b) cold, clammy skin; (c) oliguria; (d) increased serum lactate 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 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 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) DPTI SUPPLY OF OXYGEN EVR = = TTI OXYGEN NEEDS DPTI/ TI is the ratio of myocardial oxygen supply (EVR), EVR