management of cardiogenic shock: how can we improve … · iabp-shock ii trial: 6 year follow-up...
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Management of Cardiogenic Shock: How Can We Improve Outcomes?
Brian Jaski, MD, FACC, FHFSA
San Diego Cardiac Center
Sharp Memorial Hospital
October 25, 2019
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2019 SCAI Clinical Expert Consensus Statement on the Classification of Cardiogenic Shock
David A. Baran MD, FSCAI (Co‐Chair); Cindy L. Grines MD, FACC, FSCAI; Steven Bailey MD, MSCAI, FACC, FACP; Daniel Burkhoff MD, PhD; Shelley A. Hall MD, FACC, FHFSA, FAST; Timothy D. Henry MD, MSCAI; Steven M. Hollenberg MD; Navin K. Kapur MD, FSCAI; William O'Neill MD, MSCAI; Joseph P. Ornato MD, FACP, FACC, FACEP; Kelly Stelling RN; Holger Thiele MD, FESC; Sean van Diepen MD, MSc, FAHA; Srihari S. Naidu MD, FACC, FAHA, FSCAI (Chair)
Baran, DA Catheter Cardiovasc Interv. 2019;94:29-37.
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Traditional Definition of Cardiogenic Shock
Persistent SBP < 90 mm Hg not responsive to fluid administration alone
Secondary to cardiac dysfunction
Associated with signs of hypoperfusion of a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg
Baran, DA Catheter Cardiovasc Interv. 2019; 1
“Cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion”
Cold/wetDizzy
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Traditional Definition of Cardiogenic Shock
Persistent SBP < 90 mm Hg not responsive to fluid administration alone
Secondary to cardiac dysfunction
Associated with signs of hypoperfusion of a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg
Baran, DA Catheter Cardiovasc Interv. 2019; 1
Arrest (A) ModifierCPR, including defibrillation
“Cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion”
2019 SCAI Stages of Cardiogenic ShockEndorsed by ACC,AHA, SCCM, and STS
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Traditional Definition of Cardiogenic Shock
Persistent SBP < 90 mm Hg not responsive to fluid administration alone
Secondary to cardiac dysfunction
Associated with signs of hypoperfusion of a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg
Baran, DA Catheter Cardiovasc Interv. 2019; 1
Arrest (A) ModifierCPR, including defibrillation
“Cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion”
2019 SCAI Stages of Cardiogenic ShockEndorsed by ACC,AHA, SCCM, and STS
Warm/wet
BP / HR
Cold/wetDizzy
>30’ resusc.Still shock
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Stage D: Deteriorating
• Patients similar to C, but are getting worse.
• These patients have failure to respond to initial interventions > 30’: 3 Domains
58 yo M high school teacher to ER with 3 week history of SOB and weakness.
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Stage D: Deteriorating
• Patients similar to C, but are getting worse.
• These patients have failure to respond to initial interventions > 30’: 3 Domains
58 yo M high school teacher to ER with 3 week history of SOB and weakness.
Physical Exam: Anxious, cool extremitiesIntubated
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Biochem Markers:Lactate: 4.0 Creat: 2.5Bili: 1.7NT-proBNP: 8,266
Stage D: Deteriorating
• Patients similar to C but are getting worse.
• These patients have failure to respond to initial interventions > 30’: 3 Domains
58 yo M high school teacher to ER with 3 week history of SOB and weakness.
Physical Exam: Anxious, cool extremitiesIntubated
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Biochem Markers:Lactate: 4.0 Creat: 2.5Bili: 1.7NT-proBNP: 8,266
Stage D: Deteriorating
• Patients similar to C but are getting worse.
• These patients have failure to respond to initial interventions > 30’: 3 Domains
58 yo M high school teacher to ER with 3 week history of SOB and weakness.
Physical Exam: Anxious, cool extremitiesIntubated
Hemodynamics:BP 88/62, mean 74. CI: 0.84 l/min/m2PCW 31, RAP / PCW 1.07 PA 48/32, RAP 33, PAPI (PA pulse pressure/RAP): 0.48Cardiac Power Output (MAP x Cardiac output): 0.30 W
Norepinephrine 25 mcg/min.
RAP / PCW > 0.8
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Key Considerations in the Diagnosis & Management of Cardiogenic Shock
Is this cardiogenic
shock?
What is the severity?
Is it predominately LV, RV, or both?
What are the support options?
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Thiele et al. European Heart Journal 2005;26:1276-81.
Intra-Aortic Balloon Pump
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IABP
Thiele H. Circulation. 2019;139:395–403.
IABP-SHOCK II trial: 6 year follow-up
Guidelines:IABP in AMI complicated by cardiogenic shock: Class III in Europe Class IIb in United States
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“No Respect”
IABP
Thiele H. Circulation. 2019;139:395–403.
IABP-SHOCK II trial: 6 year follow-up
Guidelines:IABP in AMI complicated by cardiogenic shock: Class III in Europe Class IIb in United States
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Lim HS. Shock 2018 50:167–172, 2018
Etiology of Cardiogenic Shock: Acute Myocardial Infarction (AMI, n=26) vs. End Stage Heart Failure (ESHF, n=42)
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Lim HS. Shock 2018 50:167–172, 2018
AMI ESHF
LVEF (%) 25+3 vs. 13+2 p<0.001
Cardiac index (L/min/m2) 1.87+0.09 vs. 1.81+.08 NS
Mean arterial pressure (mm Hg) 58+3 vs. 57+2 NS
AMI
ESHF
Right heart Pressures
mm Hg
Etiology of Cardiogenic Shock: Acute Myocardial Infarction (AMI, n=26) vs. End Stage Heart Failure (ESHF, n=42)
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Lim HS. Shock 2018 50:167–172, 2018
AMI ESHF
LVEF (%) 25+3 vs. 13+2 p<0.001
Cardiac index (L/min/m2) 1.87+0.09 vs. 1.81+.08 NS
Mean arterial pressure (mm Hg) 58+3 vs. 57+2 NS
AMI
ESHF
Right heart Pressures
mm Hg
Etiology of Cardiogenic Shock: Acute Myocardial Infarction (AMI, n=26) vs. End Stage Heart Failure (ESHF, n=42)
Metabolic
Acidosis
Meq/LAMI
ESHF
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Thiele et al. European Heart Journal 2005;26:1276-81.
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Axillary IABP
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Axillary IABP
The Balloon pump is Dead, Long Live the balloon Pump!
SCAI Stages C-ESCAI Stages A-C
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Acute MI (STEMI 78%) and PCI.
100% Impella (91.8% CP)
83% vasopressors or inotropes
20% witnessed out of hospital cardiac arrest with ROSC <
30’ 29% in-hospital cardiac arrest
10% CPR during Impella implant
Creatinine 1.8 ± 2.2 mg/dL and lactate 5.4 ± 4.4 mg/dL
Impella for Cardiogenic Shock in MI
Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.
2019;93:1173–1183.
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Acute MI (STEMI 78%) and PCI.
100% Impella (91.8% CP)
83% vasopressors or inotropes
20% witnessed out of hospital cardiac arrest with ROSC <
30’ 29% in-hospital cardiac arrest
10% CPR during Impella implant
Creatinine 1.8 ± 2.2 mg/dL and lactate 5.4 ± 4.4 mg/dL
Impella for Cardiogenic Shock in MI
Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.
2019;93:1173–1183.
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Acute MI (STEMI 78%) and PCI.
100% Impella (91.8% CP)
83% vasopressors or inotropes
20% witnessed out of hospital cardiac arrest with ROSC <
30’ 29% in-hospital cardiac arrest
10% CPR during Impella implant
Creatinine 1.8 ± 2.2 mg/dL and lactate 5.4 ± 4.4 mg/dL
Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.
2019;93:1173–1183.
Impella for Cardiogenic Shock in MI
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Impella for Cardiogenic Shock in MI
Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.
2019;93:1173–1183.
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15 (12.2% of survivors) Tx’d/Eval for durable LVAD or
transplant
3 Impella RP placed in conjunction with an Impella CP
(Bipella)
5 VA-ECMO in conjunction with Impella (ECPella)
2 Converted to VA-ECMO
1 Escalated to Impella 5.0.
1 patient temporary surgical LVAD
1 patient durable LVAD
Impella for Cardiogenic Shock in MI
Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.
2019;93:1173–1183.
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Repositioning Sheath
Impella CP
Fiberoptic sensor just proximal to outlet cage
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Impella 5.5
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https://www.elso.org/Registry/Statistics.aspx
Global Number of Centers and Cases 1990-2018
ELSO Registry: Neonatal, Pediatric, and AdultCardiac, Pulmonary, eCPR
Centers Cases5x / 10 yrs
Extra-Corporeal Membrane Oxygenator
Distal leg perfusion
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Burkhoff D.J Am Coll Cardiol 2015;66:2663–74.
Greater LV contractility, vasodilation, or mechanical unloading
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Heart, Lung and Vessels. 2015; 7(4): 320-326
63/720=8.8%
Circulation 2014: 130:1095-1104.Rupprecht L, Heart, Lung and Vessels. 2015; 7:320-326.
Harlequin or North-South Syndrome: Heart +/- brain hypoxemia with LV Recovery
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Acute MCSEtiology
Therapy/Rx
EscalateHemodynamic insufficiency
Device complicationDurable device/Transplant
PalliatePatient/Family values
Clinical frailty
De-escalateMyocardial Recovery
Device Selection: Define Your Acute MCS Path
“Bridge to Nowhere”
Serfos, Greece
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PAPI < 0.9
Vascular complicationsSystemic Inflammation
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Summary:
• We don’t use hemodynamic data to guide decision-making often enough
• Match device(s) to hemodynamics/pace/etiology
• Have an exit strategy ideally before initiating acute mechanical circulatory support
• Don’t ignore the RV in shock: Impella RP vs VA ECMO for RV support
• Time matters
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Management of Cardiogenic Shock: How Can We Improve Outcomes?
Brian Jaski, MD, FACC, FHFSA
San Diego Cardiac Center
Sharp Memorial Hospital
October 25, 2019