Luis A Guzman MD, FACC, FSCAI Director, Cardiac Cath Lab ...Luis A Guzman MD, FACC, FSCAI Director,...
Transcript of Luis A Guzman MD, FACC, FSCAI Director, Cardiac Cath Lab ...Luis A Guzman MD, FACC, FSCAI Director,...
Cardiogenic Shock: A Multidisciplinary Approach
Luis A Guzman MD, FACC, FSCAIDirector, Cardiac Cath Lab
Chair, SCAI International CouncilRichmond, Virginia
Society for Cardiac Angiography
and Interventions
To improve care of patients with cardiogenic shock, we have collaborated with cardiac
surgery, Interventional cardiology, and advanced CHF to develop a “Shock” response team.
The goal is to provide more consistent, comprehensive and rapid assessment, treatment and
escalation of the shock patient.
Enclosed are recommended guidelines we have developed for triggers and timing of
consultation (slides 3 and 4) as well as early assessment recommendations (slide 6).
These recommendations are to serve as triggers to identify the decompensating patient
where intervention may prevent the further development of multiorgan failure. A simple rule
is that in general, earlier is better for having multi-disciplinary involvement.
The shock team currently should be activated by the CICU team for appropriate patients.
We have developed a group “shock” page
We are initially implementing the shock team pager Monday through Friday 7a to 7p. We are
currently exploring the ability to conference in for patients who present off hours.
VCU Shock Team Program Statement
Shock Team Members
CICUTeam
(Doctor, FellowNursing staff)
Advanced Heart Failure
CT SurgeonCardiac Surgeon
Intensivist
Interventional Cardiologist
Shock Team Guidelines
Types of Patients and Entry points
• Causes
• Acute MI
• Acute systolic heart failure (myocarditis, stress CM)
• Decompensating chronic HF
• Cardiac arrest
• Entry Points for Patients
• Transfer in Shock patient
• Determine if pre-hospital notification needed
• Direct presenting patient
• ED arrival patient
• In-patient now with worsening shock
Shock Team Consultation
• Consultation
• Critical point is to be timely
• Severe shock
• Hypotensive despite 2 drips and/or support device
• on or before pt arrival
• BP stable on 2 drips and/or support device
• within 4 hr
• stable shock
• w/in 24 hr (same day if arrives before evening)
• Page sent to team members
• Meet to decide on treatment plan: impella, ECMO, etc
• Team follow up twice daily for 48 hr
Which patients should be considered for consultationSevere Shock
• MI with IABP with pressor
• MI with impella not placed for procedural support (PCI, EP)
• Acute or unknown HF status requiring 2 drips at admission
• Stable Shock pt now worsening:
• Progressive worsening in lactate (increase >2 over 4 hr), mixed venous (decrease >10% or sustained < 50% with increased lactate) or cardiac index (<2.0 with elevated lactate) despite up-titration of drips
• Failure of lactate/mixed venous to improve by (lactate by 2, MV by 10% (which ever is greater) over 4 hrs despite increase in inotropes, pressors
• Increasing inotropes to maintain perfusion (BP, lactate, mixed venous and/or cardiac output)
Initial and serial hemodynamic assessment
• Non-invasive
• Vital signs (ie hypotension, tachycardia)
• Echo
• within 2-4 hours of admission
• Assess for LV fxn, RV fxn, valve abnl, mechanical complications
• Lab values
• Serial lactate and mixed venous/MVO2
• Should be repeated q 2-4 hr initially; if stable then at 4-6 hr
• Invasive--in selected patients
• Swan (low threshold to place)
• Goal—identify and treat patients when in LV failure state (hemodynamic shock) prior to progressing to hemo-methabolic shock
Quality Assurance Process
• Feedback is a major component of success
• Bi-Weekly or Monthly Reports
• Internal Review at Cath or CICU Conference
• Inter-Department Review
• Benchmarking with national registries
Cardiogenic Shock Team Approach
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AMI CHF Post Cardiac Arrest Myocarditis Other
Cardiogenic Shock Etiology
VCU Cardiogenic Shock Experience
Case # 1
61yo AAM w/ PMH notable for EtOH abuse, tobacco use d/o, and HTN who had a witnessed
cardiac arrest on 7/20/18 w/ agonal respirations & VF as first noted rhythm and ultimately
achieved ROSC (after CPR ~20min by family + >17min by EMS, as well as Epi x3, Amio
300mg, & shock x3) and then had EKG showing inferior MI w/ complete heartblock &
cardiogenic shock,
Taken to the Cath Lab.
Mean BP 60 mmHg with Dobutamine, Neosynephrine and Epinephrine
External Pacing dependent
Case # 1
61yo AAM w/ PMH notable for EtOH abuse, tobacco use d/o, and HTN who had a witnessed
cardiac arrest on 7/20/18 w/ agonal respirations & VF as first noted rhythm and ultimately
achieved ROSC (after CPR ~20min by family + >17min by EMS, as well as Epi x3, Amio
300mg, & shock x3) and then had EKG showing inferior MI w/ complete heartblock &
cardiogenic shock,
Taken to the Cath Lab.
Mean BP 60 mmHg with Dobutamine, Neosynephrine and Epinephrine
External Pacing dependent
Temporary PM placed
Femoral angiography performed to determine if candidate for LVAD
Impella CP placed
Coronary Angiography performed. Occluded Prox RCA. No left system issues
Successful PCI w/ DES to RCA
Arctic Protocol initiated in Cath Lab.
Serum Lactate first 24-48 hrs
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10
5
No urinary output. Creatinine 1.7 increased to 5.0 in first 24 hrs. Need dialysis
Shock Team Called at 6 hrs from PCI and following morning.
Escalation or not? If yes. Which device. ECMO or Impela RV
CO: Require 7 l of IV fluid in first 24 hrs to maintain CO and MAP
Lactate post PCI: 12. Then 9 Then 7 at 6 hrs 6.7
6 hrs post: CVP 12-15 MAP 70-80 CO 3.0-4.0 l/min CI 1.5-2.1
12 hrs post: CVP 12-15 MAP 70-80 CO 5.0-6.0 l/min CI 2.9-3.4. Decrease Drug
support DC epinephrine. Neo and dobutamine in lower dose
Since PAPI was > 1.0, PCO 1.0 and lactate was trending down, it was considered to
continue with LV support
Neuro evaluation to determine brain status
Day 3.
Arctic Protocol stopped
Patient fully responsive
CO and Hemodynamics stable with minimal Inotropic and Vasopressors
Impela at P2. patient remained stable
Impela weaning and removed
Serum Lactate and Liver Function
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10
5
400
300
200
1) Inferior STEMI, complicated by VF cardiac arrest and cardiogenic shock: s/p DES to RCA on 7/20.
Initially w/ complete heart block requring transvenous pacing. pacemaker removed on 7/22.
Patient s/p ARCTIC protocol. Impela removed 7/24. Improved overall.
2) 07-26 (Day 5) Patient develops Septic Shock:
Most likely source is the lungs with bilateral basal infiltrates
Repeat CT scans on 7/28 suggested possible left lower lobe ASD and moderate volume complex abdominal fluid
AGS was already consulted. No acute surgical indications.
- Pressor support w/ NE for MAP goal > 65 mmHg. Goal CVPs 6-12. Plan to wean as tolerated.
- Cx negative. C.diff negative.
3) Hypoxic Respiratory Failure:
ventilator requirements improving with diuresis via CRRT.
- Wean vent as tolerated.
4) Pancreatitis w/ abdominal compartment syndrome and ileus:
Lipase 2339. Bladder pressures normalized. KUB with improving gas pattern and resolving ileus. CT abdomen without need
for acute surgical intervention.
5) Acute Renal Failure:
Unknown baseline Cr but patient w/ oliguric renal failure requiring CRRT this admission
- Continue CRRT w/ goal even
6) Atrial Fibrillation: evening of 7/24 patient developed Afib w/ RVR. Currently in sinus
- Decrease Amio 400mg q 8 to BID
- Continue Bival for AC
7) Anemia, Coagulopathy in the setting of DIC:
Blood counts stabilizing. DIC has resolved. Patient is s/p 8 units of PRBC, 2 units of cryo, 1 unit of FFP, and 1 dose of
platelets this admission.
Patient Outcomes
Case # 2
75 yo Filipino woman
PMH AMI 10 years ago (reportedly with full recovery and most recent EF 55%), HTN, CKD 3, OSA on
CPAP, DM, HLD, gout
Presents as a transfer from OSH for RV failure, cardiogenic shock, 3 vessel CAD, MV regurgitation.
Admitted to the OSH with complaints of dyspnea, chest pain and lower extremity edema on 4/30/18.
Symptoms reportedly started 3-4 weeks before after a long road trip to the Midwest. She was admitted and
treated for presumed PE, her VQ scan showed moderate probability. She was evaluated by cards/pulm at
OSH and found to have severe RV dysfunction with severe elevation of RVSP and RV was dilated. BNP
was >3000. Dobutamine was started, but did not help, so aquaphersis was performed to off load fluid.
While in the OSH developed acute EKG changes and increase troponin. Had LHC that showed severe 3
vessel CAD and severe pulmonary hypertension with CI and CO consistent with cardiogenic shock.
An IABP was placed for the shock and she was transferred to VCU for CABG and MVR eval.
. Admitted to CICUFollowing morning, patient develops suddenly agitation, combative. Drop in O2 sat. Requires emergent Intubation Stroke alert called. CT scan No IC bleeding No ischemic stroke
Shock team CalledCICU team CT Surgery Interventional Cardiology CHF teamRadiology Imaging. Cardiac Imaging and Perfusionist
Detailed evaluation of hemodynamics in prior 24 hrsPulmonary HTN considered more secondary to MR than recent small PE (images of V/Q scan reviewed)Echo images discussed with imaging team. Severe RV dilatation. Severe MR. Good LVF Coronary anatomy reviewed. Considered that mainly LAD disease with no clear need for other vessel revascularizationCT surgery consider that surgical mortality was above 50% (RV failure, severe pulmonary HTN, CKD, combined surgeryCHF team. Not a candidate for advance therapy
Next steps considerationRV support to improve shock and RV failure (RV Impella vs ECMO)PCI of LAD to improve LV function and septal ischemiaHybrid approach PCI to CAD followed by MV surgeryMitral clip to MV and PCI to LAD
Discharged to SNF 05-30
05/23
Case # 3
68 YOM with a h/o ICM s/p prior CABG, and severe HFrEF (40 --> 15%) with a non-
revascularizable coronary tree via LHC performed at an OSH.
Developed sudden death (presumed VT) at his Cardiologist's office. Underwent CPR,
eventual ROSC. He was intubated and placed on pressors. Initiation of hypothermia
Arrive via EMS. He is currently on dobutamine at 10 mcg/kg per minute, Levophed at
15 mcg/minute, amiodarone drip 1 mg/hour, epinephrine drip 3 mcg/minute, and
supported on ventilator. Mean BP 50 mmHg. No urinary output. Lactate 9. Cr 1.5 ALT
468 AST 449
Swan Ganz was placed
CO 2.2
CI 1.5
PCO: 0.4
PIPA: > 1.0
Bedside Echo. EF 10%. Dilated with global severe hypokinesia
Shock Team CalledCICU team; CT Surgery; Interventional Cardiology; CHF team
Main questions
Does the patient should be considered for more advanced
support?
Do we think he will be a candidate for therapy to recovery?
or it has to be bridge to advanced therapy?
If only candidate to advanced therapy, does he qualify?
Mechanical support. Which one?
Any other therapy might improve outcome?
YES (CICU team)
NO (CICU team)
YES (CICU team)
YES (CHF team)
LVAD (CTS IC)
NO (CTS IC)
CTS placed a 5.0L Axillary Impela device
Outcome next 24 hrs
Impella provides 4.0 l/minLactate decrease to < 2Good urinary outputDobutamine 10mcg/kg/min only Inotropic supportLiver function stable No signs of InfectionsAmiodarone and Lidocaine drips
Plan; Continue same tratement
LAVD Monday
Outcome following 24 hrs
Patient developed frequent episodes of recurrent VTIncrease AmiodaroneVT storm. Non responsive to any drugs
SHOCK Team Called
Discussion and Conclusions
Not a candidate for LVAD definite therapy
EP Consulted
ECMO Placed for total support
Patient taken to EP Lab for EP Ablation
Successful VT Ablation
LVAD definite therapy
Outcome following 24 hrs
Patient developed frequent episodes of recurrent VTIncrease AmiodaroneVT storm. Non responsive to any drugs
SHOCK Team Called
Discussion and Conclusions
Not a candidate for LVAD definite therapy
EP Consulted
ECMO Placed for total support
Patient taken to EP Lab for EP Ablation
Shock Team Members
CICUTeam
(Doctor, FellowNursing staff)
Advanced Heart Failure
CT SurgeonCardiac Surgeon
Intensivist
Interventional Cardiologist Other Medical Consultants
• Medical Intensivist (if CICU)• Perfusionist• Nephrologist• Electrophysiologist• Respiratory Therapist• Pharmacist• Social worker• Palliative care
Regional System of Care for Cardiogenic Shock
AHA Scientific Statement. Circulation 2017;136; e232-e268
0
10
20
30
40
50
>100 60-100 30-60 <30
Mortality
Outcomes in AMI and Cardiogenic Shock and Hospital VolumeNCDR Registry
p: < 0.05
Shaeli S et al. JAHA 2015. 4; e1462
• Prompted Revascularization
• High volume operators
• Availability of more advanced
therapies and trained personnel
• More use of Mechanical
support
Cowger J et al. JACC: Heart Failure 2017, 5;10 :700-702
Outcomes in Cardiogenic Shock in CHF pts and Hospital VolumeINTERMACS Registry
Grupo colaborativo que incluye Cardiologo UCO, Cardiologo Interventionista, Cardiologo
Insuficiencia Cardiaca, Cirujano cardiaco y Perfusionista.
Para proveer en forma mas consistente, rapida y concensuada, la evaluacion, tratamiento
inicial y progression del tratamiento de los pacientes en shock
Debe tener pre establicidas guia de tratamiento y secuencia de parametros a seguir para
rapidamente determinar la progresion clinica y terapeutica
Una meta principal es identificar parametros de descompensacion donde la intervencion
podria preveer la rapida evolucion al shock multiorganico.
Una simple regla: Mientras mas precoz la intervencion, mejor es el resultado
Ademas del team primario, es necesaria la incorporacion de otras disciplinas de acuerdo al
paciente a tratar (medico intensivista, etc)
Para garantizar el exitio, es conveniente hacer una incorporacion progresiva del programa,
con frecuentes evaluaciones y feedback
Centros especializados en pacientes con shock probablemente sean beneficiosos para
majorar el exito de tratamiento
Shock Team Program Summary
Muchas Gracias