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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
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.
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
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
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
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.
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
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
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
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?
Thiele et al. European Heart Journal 2005;26:1276-81.
Intra-Aortic Balloon Pump
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
“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
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)
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)
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
Thiele et al. European Heart Journal 2005;26:1276-81.
Axillary IABP
Axillary IABP
The Balloon pump is Dead, Long Live the balloon Pump!
SCAI Stages C-ESCAI Stages A-C
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.
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.
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
Impella for Cardiogenic Shock in MI
Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.
2019;93:1173–1183.
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.
Repositioning Sheath
Impella CP
Fiberoptic sensor just proximal to outlet cage
Impella 5.5
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
Burkhoff D.J Am Coll Cardiol 2015;66:2663–74.
Greater LV contractility, vasodilation, or mechanical unloading
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
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
PAPI < 0.9
Vascular complicationsSystemic Inflammation
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
Management of Cardiogenic Shock: How Can We Improve Outcomes?
Brian Jaski, MD, FACC, FHFSA
San Diego Cardiac Center
Sharp Memorial Hospital
October 25, 2019