2/19/2020 HEMODYNAMIC SUPPORT IN ACUTE CARDIOGENIC SHOCK Catherine - - PDF document

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HEMODYNAMIC SUPPORT IN ACUTE CARDIOGENIC SHOCK

Catherine T. Prince, DO, PhD, MPH, FACC Northstate Cardiology Consultants

HPI

• 62 y/o WM
• Over the past 3-5 months the patient

was experiencing worsening SOB

• No other PMH/PSH
• Presented to OSH with several hours of

chest pain

• EKG showed anterolateral/inferior

STEMI

• Transferred to Enloe for cath/PCI and

was hemodynamically stable upon arrival to ED

INITIAL DATA Pre procedure vitals

HR – 79 BP – 113/76 RR - 20 SPO2 – 95%

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DIAGNOSTIC ANGIOGRAM

EVENTS IN THE CATH LAB

• In the CCL, the patient had multiple VF episodes that required multiple defibrillations
• CPR was performed
• Patient was intubated
• Patient was hypotensive and continued to have ventricular arrhythmias
• Impella CP was placed via left femoral artery

IMPELLA PRE-PCI

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DIAGNOSTIC ANGIOGRAM

INTERVENTIO NAL STRATEGY

• 6 Fr right radial arterial access
• 6 Fr EBU 4.0 guiding catheter
• BMW 0.018” to proximal LAD
• Pre dilation of the proximal LAD with a 2.5 mm x 15

mm Sprinter balloon

• 2nd BMW 0.018” to LCx
• 3.5 mm x 34 mm Resolute Onyx DES was deployed

in the LAD

• Post dilation of the proximal LAD with a 3.5 mm x

14 mm NC Stormer balloon

INTERVENTION

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INTERVENTION

INITIAL DATA

Pre procedure vitals

HR – 79 BP – 113/76 RR - 20 SPO2 – 95%

Labs

CK-Total - 466 Troponin - 384

GTTS

No GTTS upon arrival to CCL

THE FOLLOWING DAY

Right Heart Cath

• PA – 29/19 (23)
• PCWP – 20/18 (15)
• Fick CO – 3.89 L/min
• Fick CI – 1.83 L/min/m2
• CPO (3.89 x 69/451)
• 0.59 Watts
• Impella replaced due positioning
• Started on milrinone as well

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SUMMARY

• A 62 y/o WM presented from an OSH with an

anterolateral/inferior STEMI

• Upon arrival to the CCL the patient had multiple VF

episodes requiring defibrillation & ACLS

• Impella was placed pre PCI
• Successful PCI to the pLAD was performed
• Next Day patient still required support based on

RHC numbers

• CO – 3.89 L/min
• CI – 1.8 L/min/m2
• CPO – 0.59 Watts
• After 2 days, stable with inotropic support, Impella

removed

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NON-ISCHEMIC SHOCK HPI

• 50 y/o WM
• PMH
• hyperlipidemia
• Hypertension
• PSH
• Fracture surgery
• Social History
• Alcohol use ~14 beers/week
• Former smoker
• Past history of marijuana use
• Sudden onset of bilateral paresthesias

in feet

• Presented to the ED with evidence of

septic shock

• Severe hypotension with BP in the 70s

while in the ED

• Admitted to the ICU and started on

pressors overnight

• Echo revealed a LVEF of ~20% with

global hypokinesis and

• No prior history of CAD

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INITIAL DATA

Pre procedure vitals

HR – 140 BP – 86/57 RR – 35 SPO2 – 100%

Labs

WBC – 35.5 BUN - 40 Creatinine – 2.9 Worsening acidosis

GTTS

Levophed Vasopressin

ECHOCARDIOGRAM ASSESSMENT

• Mixed septic and cardiogenic shock presentation
• Sent to the ICU overnight on pressors
• The patient decompensated in the ICU needing an

increase in pressor support

• ABG showed worsening acidosis, patient was

intubated

• It was determined that the patient was suffering

from biventricular failure that required mechanical circulatory support

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SUMMARY

• 50 y/o WM patient presented to the ED in septic

shock

• The patients condition worsened in the ICU
• It was determined that this patient was in septic &

cardiogenic shock with biventricular dysfunction

• The patient had a PEA arrest while being

transported to the helicopter and was determined too unstable to transport at that time

DIAGNOSTIC ANGIOGRAM

RIGHT HEART CATHETERIZATION

• RA – 20
• RV – 43/13 (23)
• PA – 39/27 (33)
• PCWP – 25
• Fick CO – 4.26 L/min
• Fick CI – 1.78 L/min/m2
• CPO – 0.71 Watts
• PAPi – 0.67

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IMPELLA PLACEMENT

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FEMORAL ANGIOGRAM (U/S + MP ACCESS)

• The LFA was accessed with a

micro puncture kit under U/S guidance

• Micro puncture sheath was

upsized to a 6 Fr sheath then preclosed x2 with 6 Fr Proglide Perclose device

• A 14 Fr x 13 cm Abiomed oscor

peel away sheath was then inserted in the LFA

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IMPELLA SUPPORTED HIGH RISK PCI

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HPI

• 93 y/o WM
• CC of stable angina
• NKDA
• Past Medical History
• CAD
• Prior stents in 1995
• Hypertension
• Dyslipidemia
• TIAs
• Severe AS

INITIAL DATA

• Diagnostic cardiac catheterization showed
• Distal LM stenosis
• LAD & LCx bifurcation disease
• LV EF 55-60%
• Severe aortic stenosis
• Valve area 0.6 cm2
• The patient refused surgery and was

consulted for a BAV + Impella supported HRPCI

• TAVR to follow HRPCI

SEVERE AORTIC STENOSIS

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DIAGNOSTIC ANGIOGRAM ACCESS

• Bilateral common femoral arterial access

was obtained with a micro puncture kit with U/S guidance

• RFA was upsized to an 8 Fr x 45 cm

destination sheath

• Micro puncture sheath was upsized to a 6 Fr

sheath then preclosed x2 with 6 Fr Proglide Perclose device

• A 14 Fr x 13 cm Abiomed oscor sheath was

then inserted in the LFA

INTERVENTIONAL STRATEGY - BAV

• Balloon aortic valvuloplasty
• Pre BAV peak to peak gradient was 50 to

55 mmHg

• A 20 mm true flow balloon was inflated for

10 seconds

• Post BAV peak to peak gradient was 35 to

40 mmHg

• No RV pacing was performed due to the

true flow balloon profile

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IMPELLA PRE-PCI INTERVENTION

INTERVENT IONAL STRATEGY

• 8 Fr EBU 3.5 guiding catheter
• BMW 0.014” to LCx
• 2nd BMW 0.014” to the LAD
• Predilation of the Ostial LCx with a 2.5mm x 12mm

balloon

• Predilation of the Ostial LAD/Distal LM with a

3.0mm x 12mm balloon

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INTERVENT IONAL STRATEGY CONTD.

• 2.5mm x 15mm Resolute Onyx DES was deployed

to the LCx

• 3.0mm x 22mm Resolute Onyx DES was deployed

to the LAD

• A Jailed Stent technique was performed
• dLM/Ostial LAD was then post dilated with a 4.0mm

NC balloon

• Whisper 0.014” guidewire was used to cross the

LCx Stent struts

• Kissing balloon angioplasty to the dLM bifurcation

was done with good result using 3.5mm x 12mm NC & 3.0mm x 12mm NC balloon

• Final post dilation using a 5.0mm NC balloon was

successfully performed

INTERVENTION

SUMMARY

• The patient tolerated the procedure well
• Impella was successfully weaned and explanted at the end of the

procedure

• Both Right & Left CFA were closed with Perclose
• Ordered to ambulate in AM
• The patient was discharged next day
• Scheduled for TAVR in Jan/Feb

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