270.3 🩺 內科專科考前版

270.3.0.1 1⃣ DanGER-SHOCK Trial (2024)

  • Impella CP vs standard care in AMI + cardiogenic shock
  • Improved mortality with Impella
  • Practice-changing
  • Increased Impella use in modern era

270.3.0.2 2⃣ ECPR (Extracorporeal CPR)

  • VA-ECMO during cardiac arrest
  • ARREST trial 2020: superior outcomes in select patients
  • Witnessed arrest + shockable rhythm + young + reversible cause + limited comorbidities
  • ECPR teams in specialized centers

270.3.0.3 3⃣ LV Decompression with VA-ECMO

  • Major issue: VA-ECMO causes LV overload (no native LV ejection but high afterload from arterial flow)
  • LV distension → pulmonary edema + worse outcomes
  • Solutions:
    • Impella CP (combined “ECPELLA”)
    • Atrial septostomy
    • Surgical LV vent
    • Maintain native LV ejection (inotrope)

270.3.0.4 4⃣ Norepinephrine vs Dopamine (SOAP II)

  • SOAP II (NEJM 2010): norepinephrine vs dopamine for shock
  • No significant mortality difference
  • Less arrhythmia with norepinephrine
  • Sub-group: cardiogenic shock had increased mortality with dopamine
  • Norepinephrine = first-line vasopressor

270.3.0.5 5⃣ Acute Mitral Regurgitation Post-MI

  • Papillary muscle rupture
  • Sudden onset pulmonary edema + cardiogenic shock
  • New holosystolic murmur at apex
  • TTE/TEE for diagnosis
  • Emergent surgical mitral repair/replacement
  • MCS bridging

270.3.0.6 6⃣ Ventricular Septal Rupture (VSR)

  • Post-MI mechanical complication (3-7 days post)
  • New holosystolic murmur at left sternal border
  • Echo + step-up in O2 saturation in PA
  • Emergent surgical repair (or transcatheter VSR closure in select)
  • High mortality (50%+ surgical)

270.3.0.7 7⃣ Tamponade Differential

  • Pericarditis with effusion
  • Aortic dissection (Type A with hemopericardium)
  • Trauma
  • Iatrogenic (post-procedure)
  • Malignancy
  • Uremia
  • Treat underlying + drainage

270.3.0.8 8⃣ 健保 / Taiwan

  • 健保 IABP + Impella + VA-ECMO available in tertiary centers
  • Shock teams emerging in major hospitals
  • 健保 advanced HF programs growing
  • Heart transplant program established (Taipei + Kaohsiung)

270.3.0.9 9⃣ Cardiogenic Shock Management Pearls

  • Time is muscle / time is heart
  • Early MCS in refractory cases
  • Multi-disciplinary approach
  • High-volume center transfer
  • Complete revascularization if culprit + multivessel (later staging)
  • Mechanical complications: emergent surgery

270.3.0.10 10. Future + Innovations

  • AI-guided shock management (real-time decision support)
  • Wearable circulatory support
  • Bioartificial heart in development
  • Pediatric MCS expansion
  • Long-term LVAD improvements
  • Total artificial heart