cardiogenic shock team Sandeep Nathan, MD, MSc, FACC, FSCAI - - PowerPoint PPT Presentation

Key elements of a cardiogenic shock team

Associate Professor of Medicine Medical Director, Cardiac Intensive Care Unit Director, Interventional Cardiology Fellowship Program Co-Director, Cardiac Catheterization Laboratory University of Chicago Medicine | Chicago, IL

Sandeep Nathan, MD, MSc, FACC, FSCAI

Getinge symposium | SCAI 2019 | Las Vegas

Disclosures

Affiliation/Financial Relationship Company

• Grant / Research Support

None relevant

• Consulting / Advisory Panel / Honoraria

Abiomed Cardiovascular Systems, Inc Getinge Terumo Interventional Systems

• Major Stock Shareholder/Equity

None

• Royalty Income

None

• Ownership / Founder

None

• Intellectual Property Rights

None

• Other Financial Benefit

None

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Therapeutic targets in the management of cardiogenic shock

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Progression of cardiogenic shock from a hemodynamic problem to a cardiometabolic syndrome

Reyentovich, A., et al. Nature Reviews Cardiology 2016.

Myocardial ischemia Hemodynamic instability Volume overload & systemic hypoperfusion Coronary perfusion End-organ dysfunction

Clinical stability Death

Culprit PCI Vasoactives → LV/RV unloading w/pMCS Escalation of pMCS / devices in combo? Complete revasc?

Renal & hepatic unloading, renal replacement Rx

ECG ’s, sxs,  cardiac biomarkers MAP, LV-ESP & EDP Aortic pulse pressure Pulmonary edema, BNP, Neuro ’s, lactate ECG ’s,  biomarkers, ventricular arrhythmias Creatinine, LFTs, lactate, coagulopathy

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Right ventricular failure (RVF) / RV shock

• Right ventricular failure (RVF) results from any structural or functional

process(es) that decrease the RV’s ability to pump blood into the pulmonary circulation

• RVF and/or RV shock are rarely seen in isolation in the critically ill patient
• utside of pure RV infarction
• RVF is increasingly being recognized as a key contributing factor to critical

illness across a variety of medical and cardiac illnesses

• The addition of RVF to critical illness portends poorer outcomes although the

magnitude of this negative impact remains poorly characterized

• The pathophysiology of RVF, as with LVF, is complex and varied but

remains less studied than LV failure

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Is it really as distinct as LV- vs. RV-shock?

• Hemodynamically defined RV dysfunction is common in AMI-CS and is largely undetected in

the absence of invasive hemodynamic assessment

Esposito M., and Kapur, N. F1000Research. 2017. Lala A, et al. J Cardiac Fail 2018;24:148–156. ML-0801 Rev A/MCV00091529 REV A 6

Goals of care in cardiogenic shock

Early recognition & triage Standardized diagnostic criteria Defined classes & stages Multimodality assessment of cardiac and end-organ function Early & continuous multidisciplinary input Clear delineation of the initial careplan & escalation strategy Early revascularization (when appropriate) Appropriate selection & early use of MCS Rapid escalation (or de-escalation) of care, as required Involvement of consultants & ancillary service providers Improved survival to discharge and beyond Emergency medical providers & primary service (CCU / CVICU) Multidisciplinary Cardiogenic Shock Team:

• Interventional

Cardiology

• Advanced Heart

Failure & Transplant

• CV Surgery
• Cardiac Critical

Care Primary service provider

1 2 3 4 5 6 7 8 9 10

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Goals of percutaneous circulatory support

• Decrease preload
• Decrease afterload
• Augment cardiac
• utput / power

Provide adequate

• rgan perfusion

and O2 delivery Bridge patients to

• Recovery
• Decision
• Durable VAD
• Transplant

Support patients through high-risk procedures

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Establishing care pathways for cardiogenic shock

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What therapies can your center deliver 24/7? Level 1 Level 2 Level 3

• Multiple percutaneous and surgical

support devices

• VAD and transplant programs
• Cardiac arrest & ECLS protocols
• Percutaneous devices and surgical

support options

• STEMI program
• No or limited percutaneous support

devices Smaller community hospitals Larger community hospitals Some teaching hospitals Quaternary centers / large academic medical centers

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Level 1 or “Full-service” program

• Primary management:

– Advanced heart failure specialist – Interventional cardiologist / Cardiac intensivist

• Device deployment / management / escalation:

– Interventional cardiologist – Cardiac surgeon

• Core team members:

– ICU pharmacist – Perfusionist – Advanced cardiac fellows – APN / RN

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Level 2 or “Mid-level” program

• Primary management:

– Heart failure specialist / Interventional cardiologist – (Cardiac) intensivist

• Device deployment / management:

– Interventional cardiologist – +/- Cardiac surgeon

• Core team members:

– Pharmacist – Perfusionist – APN/RN

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Level 1 care for cardiogenic shock

Pathway for instituting a shock program

Clear agreement between all key stakeholders regarding indications, contraindications and programmatic goals.

Assembly of a 24/7/365 multidisciplinary cardiogenic shock team

INSTITUTIONAL & SPECIALTY- SPECIFIC “BUY-IN”

SHOCK TEAM APPROACH

Key issues:

• Implanting MDs

& location,

• Explanting

MDs, location & timing

• Bed geography

OPERATOR TRAINING, COORDINATION OF CARE DELIVERY, THROUGHPUT & LOGISTICS

NURSING, TECH, PERFUSION SUPPORT & ICU CARE

• Establish initial &

repeating training for nurses & techs.

• Have a clear

understanding with perfusionists.

• Train ICU nurses &

designate receiving units

EQUIPMENT & INVENTORY ISSUES

Key issues:

• Hardware
• wnership, ratios

& location

• Disposables
• Cath lab vs.

OR/C-arm vs. procedure room

• vs. HOR?
• ECLS cart

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Level 1 care for cardiogenic shock

Key members of the shock team

Assembly of a 24/7/365 multidisciplinary cardiogenic shock team SHOCK TEAM APPROACH SUPPORTING STAFF

• 1. Vascular Surgery
• 2. Cath Lab: Nurses,

Technologists (ideally with 1 “super-user” each)

• 3. ICU: Nursing

leadership support

• 4. Perfusionists

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Interventional Cardiology Cardiac Critical Care Specialists Cardiovascular Surgery Advanced Heart Failure

ED & IC EMS

Level 1 care for cardiogenic shock

Chain of communication within the center

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Level 1 care for cardiogenic shock

Chain of communication within the center

Shock team decision HF, ICU & CV surgery IC ED

Key issues to resolve:

• Initial care plan including MCS, vasoactive support, ICU care
• Identifying NOK / POA
• Identifying goals of care / limitations to care
• Chart out escalation plan
• Decide on timing of next clinical / hemodynamic “snapshot”

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Protocolizing cardiogenic shock care

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Activate Cardiac Cath Lab

Yes No

Access Assess Hemodynamics pMCS Reassess Hemodynamics Acute MI? Coronary Angiogram with PCI Begin Weaning Catecholamines*

PCI: Coronary angiography and PCI with goal of complete revascularization.

Access:

• 1. Femoral arterial access using micropuncture with

image guidance (ultrasound and/or fluoroscopy)1

• 2. Angiography via 4F micropuncture dilator to

confirm puncture site & vessel size

• 3. Place appropriately sized (5 or 6 Fr) arterial

sheath

• 4. Obtain venous access (femoral or internal

jugular) Assess Hemodynamics: LVEDP or PAC

• If sustained hypotension (SBP < 90 mmHg) for > 30 min

Or

• CI < 2.2 with LVEDP or PCWP >15 mmHg,

consider mechanical circulatory support

If femoral arterial anatomy suitable and no contraindications, place, or escalate to (if IABP already in place), Impella 2.5 or Impella CP

BEST PRACTICES BEST PRACTICES

* If consistent with overall hemodynamic management CO, cardiac output; CPO, cardiac power output; dPAP, diastolic pulmonary arterial pressure; MAP, mean arterial pressure; PAC, pulmonary arterial catheter; PAPi, pulmonary artery pulsatility index; RA, right arterial pressure; sPAP, systolic pulmonary arterial pressure. Soverow J, Lee MS. J Invasive Cardiol. 2014;26(12):659-667

Step 1: Objectively assess, stabilize & perform complete revascularization

Reassess Hemodynamics: PAC (if not done initially) 1. CPO = (CO  MAP)/451 2. PAPi = (sPAP-dPAP)/CVP ML-0801 Rev A/MCV00091529 REV A 18

CPO < 0.6 CPO > 0.6 PAPI

< 1 ≥1

RV Preserved: Escalate MCS or consider transfer to LVAD/Transplant Center

RV Dysfunction: Right-sided MCS (T/C Impella RP)

Reassess Hemodynamics via PAC prior to Discharge from the Cath Lab:

• 1. Cardiac Power Output (CPO) = (CO  MAP) / 451
• 2. Pulmonary Artery Pulsatility Index (PAPI) = (sPAP-dPAP) / CVP

Admit to ICU to maximize supportive care and to actively assess for myocardial recovery

Yes No

Persistent Hypoxemia? PaO2 < 55 on 100% FiO2 Consider higher power support device

Anderson MB, et al. J Heart Lung Transplant. 2015;34(12):1549-1560.

RV Failure as defined by Recover Right1:

• CI < 2.2 L/min/m2 (despite continuous infusion
• f ≥ 1 high dose inotrope, ie, da/dobutamine

≥ 10 µg/kg/min or equivalent) and any of the following:

• 1. CVP > 15 mmHg, or
• 2. CVP/PCWP or LAP ratio >0.63, or
• 3. RV dysfunction on TTE

(TAPSE score ≤14 mm)

Step 2: Reassessment prior to discharge from cardiac cath lab

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Step 3: Consideration for escalation, weaning and transfer for higher level care

Assess for Myocardial Recovery

(At least every 12 hours)

Continue MCS support & frequent clinical reassessment Failure to recover within 48-72 h, consider escalation or durable VAD/transplant Improving Clinical, Echocardiographic & Hemodynamic parameters (concordant):

• ↑ Cardiac output
• ↑ CPO
• ↑ Urine output
• ↓ Lactate
• Inotropes low dose/discontinued
• Adequate Ramp test

Wean & Explant MCS (After a clinically-determined duration

• f support)

Worsening Clinical, Echocardiographic & Hemodynamic parameters (concordant):

• ↓ Cardiac output
• ↓ CPO
• ↓ Urine output
• ↑ Lactate
• Inotrope dependent
• Absent pulsatility

Mixed picture Clinical, Echocardiographic & Hemodynamic parameters (discordant):

• Some parameters are improving
• Pressors lowered but not

discontinued

• Fails “ramp test”

No Recovery Escalate or Transfer

Refer to institutional protocol for escalation or transfer

Inadequate Recovery Myocardial Recovery

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Tehrani, B.N. et al. J Am Coll Cardiol. 2019;73(13):1659–69.

INOVA H&V Institute protocol for CS

Compared with 30-day survival of 47% in 2016, 30-day survival in 2017 and 2018 increased to 57.9% and 76.6%, respectively (p < 0.01)

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INOVA risk prediction model for mortality in CS

• Independent predictors of 30-day mortality were age >71 years, diabetes mellitus, dialysis, >36 h of

vasopressor use at time of diagnosis, lactate levels >3.0 mg/dl, CPO <0.6 W, and PAPi <1.0 at 24 h after diagnosis and implementation of therapies.

• Either 1 or 2 points were assigned to each variable, and a 3-category risk score was determined: 0 to 1

(low), 2 to 4 (moderate), and >5 (high).

Tehrani, B.N. et al. J Am Coll Cardiol. 2019;73(13):1659–69. ML-0801 Rev A/MCV00091529 REV A 22

The Shock Team in action: Clinical profile of a cardiogenic shock patient

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Profile of an IHCA/CS patient

57 yo male presenting off-hours w inferior STEMI , sx to door: 60-90 min, hemodynamically stable in ED; door to cath lab transport: 27 min As patient brought to CCL, PMVT → VF arrest. 25+ minutes of intermittent cardiac arrest with LUCAS-assisted CPR; IABP considered but Impella CP used 2/2 lack of organized rhythm. PCI performed of large RCA with heavy thrombus burden. ROSC regained after RCA opened; patient transferred to CCU intubated, on low-dose epinephrine gtt and Impella CP with intravascular cooling started but terminated early because of meaningful neurologic activity 1-2 hrs after completion of PCI Patient discharged alive 1 week later with no neurologic deficits & normal LVEF; Alive & well 6+ mo. later, back to working full time

EMS→ ED→ IC

IC/CICU IC+HF+ CV Surg IC+HF+ CICU IC/Gen Card

Ideal profile of the IHCA/CS patient

* Images used with the patient’s permission.

Summary

• Cardiogenic shock represents a dynamic set of conditions, presentation

profiles and pathophysiologic mechanisms. Thus, CS care requires continuous monitoring and willingness to adjust the treatment plan.

• Biventricular dysfunction is more common than recognized therefore

assessment of both RV and LV function is critical.

• Time, team and treatment choices are all equally important in

combating shock.

• Given the lack of clear superiority of any one device, protocols and

standardization are keys to success.

• Integration of device therapy with system of cares is likely to offer the

greatest impact on outcomes.

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Thank you!

Email: snathan@medicine.bsd.uchicago.edu | Twitter: @SandeepNathanMD

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