Key elements of a cardiogenic shock team · 2019-05-21 · Right ventricular failure (RVF) / RV...

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

outside 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.

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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

output / power

Provide adequate

organ 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

devicesSmaller 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 shockPathway 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

ownership, 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 shockKey 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 shockChain of communication within the center

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Level 1 care for cardiogenic shockChain of communication within the center

Shock team

decision

HF, ICU & CV

surgeryICED

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 PRACTICESBEST 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

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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 maximizesupportive 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

of ≥ 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

of 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 RecoveryEscalate or Transfer

Refer to institutional protocol

for escalation or transfer

Inadequate RecoveryMyocardial 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.

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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: @SandeepNathanMDML-0801 Rev A/MCV00091529 REV A26