Cardiogenic Shock: Teams of Teams Alexander G. Truesdell, MD - - PowerPoint PPT Presentation

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Cardiogenic Shock: Teams of Teams Alexander G. Truesdell, MD - - PowerPoint PPT Presentation

Sep 25, 2023 210 likes •556 views

Cardiogenic Shock: Teams of Teams Alexander G. Truesdell, MD Virginia Heart Falls Church, Virginia, USA @agtruesdell Disclosures Consultant, Abiomed Inc. Speakers Bureau, Abiomed Inc. Objectives Background Managing Cardiogenic

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Cardiogenic Shock: “Teams of Teams”

Alexander G. Truesdell, MD

Virginia Heart Falls Church, Virginia, USA @agtruesdell

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Consultant, Abiomed Inc. Speakers Bureau, Abiomed Inc.

Disclosures

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  • Background
  • Managing Cardiogenic Shock in 2019
  • Paradigm Shift: “S2S”
  • Identifying “Best Practices”
  • Teamwork Makes the Dream Work

Objectives

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Cardiogenic Shock Mortality

  • Persistently high mortality: plateau, decrease in 1990s, plateau
  • Pressors: Increased myocardial oxygen consumption and impaired microcirculation (harm)
  • Early revascularization: necessary…but not sufficient…
  • Time-sensitive survival: need right treatment, right time, right place…

Killip et al Am J Cardiol 1967 Wayangakar et al JACC Interv 2016 Hochman et al NEJM 1999 Scholz et al Eur Heart J 2018 Samuels et al Journal of Cardiac Surgery 1999 Krishnan et al Int J Cardiol 2017 Goldberg et al NEJM 2001 Thiele et al NEJM 2017 Goldberg et al Circulation 2009 Obling et al Eur Heart J Acute Cardiovasc Care 2018 Kunadian et al JACC Interv 2014 Strom et al Eurointervention 2018 Shacadia et al JACC Interv 2018 Wong et al Can J Cardiol 2019

Killip 1967 CULPRIT-SHOCK 2017 SHOCK 1999

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Kohsaka et al Arch Intern Med 2005 Kapur et al www.acc.org 2016 Johansson et al Crit Care 2017

Clinical Objectives in Shock

Maintain Vital Organ Perfusion Reduce Myocardial Oxygen Demand Increase Coronary Flow Interrupt SIRS Response

SIRS

Free radical defense, Inhibitors, Antibodies, ???

Percutaneous VAD PCI ?

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Seyfarth et al JACC 2008 Thiele Lancet 2013 Cheng Ann Thorac Surg 2014 Kapur et al www.acc.org 2016

Is There A “Goldilocks” Device?

Minimal benefit in clinical trials No LV unloading Labor intensive (Bi-Pella/EC-Pella)

  • Easy, percutaneous

implantation

  • Effective, reliable

circulatory support

  • Maintain systemic

perfusion pressure

  • Ventricular unloading
  • Easy to manage post-

insertion

  • Low complication

rates (limb ischemia, stroke, hemolysis)

Rihal et al Catheter Cardiovasc Interv 2015 Van Diepen et al Circulation 2017 Mandawat et al Circ Interventions 2017

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Keeley et al Lancet 2003 Tchantchaleishvili et al JAMA Surgery 2015 Shavadia et al JACC Interv 2018 Wong et al Can J Cardiol 2019 https://www.henryford.com/cardiogenicshock

  • Drugs and devices don’t work by

themselves…

  • Protocols, pathways, systems of care are

required to address complex medical problems…

  • Is PCI better than tPA…in the absence of an

associated system of care?

  • Other successful systems of care: STEMI,

Stroke, Trauma…

The “NCSI Argument”…

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Team of Teams

  • EMS
  • Emergency Medicine
  • Interventional Cardiology
  • Echocardiography
  • Cardiothoracic Surgery
  • Perfusionist
  • Critical care
  • Advanced Heart

Failure/Transplant

  • Full ancillary services
  • Telemedicine
  • Triage
  • Communications
  • Transport
  • 24/7 on-site personnel
  • Decision-making
  • Leadership
  • Protocols
  • Volume/Expertise
  • Quality
  • Plug-and-play options
  • Outcomes
  • Research

Haft et al Ann Thorac Surg 2010 Doll et al Catheter Cardiovasc Interv 2015 McChrystal et al Team of Teams 2015 Atkinson et al JACC: Interv 2016 Truesdell et al Interv Cardiol 2018

  • Decrease time to

intervention

  • Initiate advanced therapies

early

  • Full-spectrum management
  • “What if you could combine the adaptability, agility, and

cohesion of small teams with the power and resources of a giant

  • rganization?”
  • “Leaders looked at the best practices of the smallest units and

found ways to extend them to thousands of people on three continents”

  • “The task force became a ‘team of teams’ – faster, flatter, more

flexible”

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van Diepen et al Circulation 2015 Nathens et al Lancet 2004 Graham et al Circulation 2012

  • What “level” are you?
  • Are you part of a larger Level I, II, III “network (team)”?

Kern et al Circ Journal 2014 Tchantchaleishvili et al JAMA Surgery 2015 Rab et al JACC 2018

Tiers of Care…

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INOVA–SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739 Tehrani et al JACC 2018 Truesdell et al Interv Cardiol Rev 2018 Tehrani et al JACC 2019 Rosner et al IAMS 2019

INOVA: In The Beginning…

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INOVA: Our Journey…

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  • “One-call” system
  • CICU Critical

Care/Cardiology co- Attendings, Cardiac Surgery, Interventional Cardiology, Advanced Heart Failure

  • Rapid, collaborative

decision-making

  • “Bedside” or “Virtual”

consultation

  • Consensus plan of care
  • Early MCS (as appropriate)
  • Hemodynamic-guidance
  • Formalized process…

INOVA–SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739 Tehrani et al JACC 2018 Truesdell et al Interv Cardiol 2018 Tehrani et al JACC 2019 Rosner et al IAMS 2019

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  • Multidisciplinary team-based care
  • Rapid identification of the shock

state

  • Early employment of (LV and RV)

MCS as appropriate [progressive shift from IABP to Impella: 2016 to 2019]

  • Hemodynamic assessment and

guidance

  • Minimize vasopressors and

inotropes

  • Survival and Recovery
  • All-comer population (AMI-CS,

ADHF-CS, OHCA, concomitant Septic Shock etc.)

INOVA–SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739 Tehrani et al JACC 2018 Truesdell et al Interv Cardiol 2018 Tehrani et al JACC 2019 Rosner et al IAMS 2019

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  • Ongoing (standardized)

multidisciplinary reassessment

  • Progression/Escalation vs.

Recovery/Weaning vs. Futility

  • “Unblinking Eye”: standard

reassessment methods (and intervals)

  • Build order sets, metrics,

tracking into EHR…

INOVA–SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739 Tehrani et al JACC 2018 Truesdell et al Interv Cardiol 2018 Tehrani et al JACC 2019 Rosner et al IAMS 2019

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  • Bedside or “Virtual” consultation
  • Real-time LVEDP, MAP, CPO, Flow (to integrate with Swan)
  • Support, weaning, escalation, trends…
  • Real-time remote data access/viewing

SmartAssist Impella Connect

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After Action Reviews…

U.S. Army TC 25-20 1993 Doll et al Circ Outcomes 2017 Truesdell et al Interv Cardiol 2018

  • What was planned?
  • What really happened?
  • Why did it happen?
  • What can we do better next

time?

  • Action plan, due-outs,

timeline…every single time…

  • Become a learning
  • rganization…
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Tests of Change Responsible Dates of test Results

  • 1. Adoption of one-call

activation

Cardiac Access, Johnny Ellis July 2017 Dec 2017 July 2018 Dec 2018 Number of CS team activations were measured and all calls were recorded to assess multidisciplinary team participation. In 2017, there were 140 team activations. In 2018, there were 159 team activations. There was >80% compliance with full team participation in shock activation calls.

  • 2. Adoption of algorithm

CS Team July 2017 Dec 2017 July 2018 Dec 2018 Right heart catheterization performed: Jan- Jun 2017: 70% of patients with CS Jul- Dec 2017: 82% of patients with CS Jan- Jun 2018: 97% of patients with CS Jul- Dec 2018- 99% of patients with CS

  • 3. Effectiveness of overall

strategy

CS Team July 2017 Dec 2017 July 2018 Dec 2018 30 Day survival increased every 6 months: Jan- Jun 2017: 55% survival Jul- Dec 2017: 62.5% survival Jan- Jun 2018: 76.5% survival Jul- Dec 2018: 72.8% survival

INOVA–SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739 Tehrani et al JACC 2018 Truesdell et al Interv Cardiol Rev 2018 Tehrani et al JACC 2019 Rosner et al IAMS 2019

INOVA: Performance Metrics…

:

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INOVA–SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739 Tehrani et al JACC 2018 Truesdell et al Interv Cardiol Rev 2018 Tehrani et al JACC 2019 Rosner et al IAMS 2019

INOVA: Results…

AMI ADHF

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Case Study

  • 47 year-old man
  • Hyperlipidemia, Tobacco use
  • Pre-hospital ECG: Anterolateral STE
  • VF arrest in ED with Defibrillation/Intubation
  • BP 90s, HR 100s/Sinus
  • To Cath Lab
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  • Antero-lateral STEMI
  • Culprit proximal LAD thrombotic occlusion
  • OM1 ostial 70% stenosis
  • RCA minimal disease
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  • 3.5mm x 32mm DES
  • Long case, recurrent slow reflow
  • “Successful” PCI
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  • EF 25%, anterior/apical dyskinesis
  • IABP 1:1, Dopamine “support” initiated for hypotension
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Hemodynamics (post-PCI/IABP)

HR 110s/Sinus SBP 90s RA 10 RV 30/8 PA 28/15 PCW 18 LVEDP 28 PA Sat 67% (FiO2 100%) CI 2.0 (not calculated in Lab) CPO 0.4 (not calculated in Lab) PAPi 1.3 (not calculated in Lab) Dopamine 20 mcg

  • Admit to ICU
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Hemodynamics (next AM)

HR 90s/Sinus CVP 17 PA 36/19 Dopamine 20 mcg Levophed 20 mcg IABP 1:1 Fick CI 1.7 CPO 0.4 (not calculated) PAPi 1.0 (not calculated)

  • Rising Lactate, Cr, LFTs
  • Inter-facility transfer to CICU

Personal Biases:

  • Pressors are poison…
  • ”Too high” MAP goals lead to harm…
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  • Progression from hemodynamic problem…to “hemo-metabolic” problem…
  • Intervene…before…reversible becomes irreversible…

Ouweneel et a JACC 2016 Esposito et al F1000 Research 2017 Kapur et al Interv Cardiol Clin 2017 Lawler et al JHLT 2018 Vallabhajosyula et al JACC 2019

Windows Of Opportunity…

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  • 47 year-old 80kg man
  • Occlusive IABP (“Shock” vessels with high-dose pressors)
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Multi-disciplinary Decision-Making

Impella ECMO

(17 Fr A, 25 Fr V)

EC-Pella

Karaltolios et al Int J Cardiol 2016 Lim Artif Organs 2017 Mourad et al ASAIO Journal 2017 Nalluria et al J Exp Rev Med Device 2017 Pappalardo et al Eur J Heart Fail 2017 Lala et al J Cardiac Fail 2018 Overtchouk et al Eurointervention 2018 Patel et al ASAIO Journal 2018

  • Progression of failure: from LV to

BiV…

  • > 24 hours since initial insult
  • Rising Cr, LFTs
  • Worsening oxygenation
  • IV, CT Surgery, CCU, CritCare, HF
  • Bi-Pella vs. EC-Pella?
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Pappalardo et al Eur J Heart Fail 2017 Russo et al JACC 2019 Dzavik et al JACC 2019

  • Concomitant tx with VA-ECMO and Impella (LV Unloading) may improve outcomes compared

with VA-ECMO alone…

  • ? also shorten ECMO duration…
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  • EC-Pella
  • ECMO decannulated

after 3 days

  • #PercAx Impella

removed after 6 days

  • Milrinone weaned
  • ff after 8 days

Hospital Course

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  • Normalized LV systolic function
  • Fick CI 4.3 L/min
  • Off all support
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Final Status

  • Discharged to home on HD #28
  • Back to work full-time
  • What might this have looked like…if…patient had received Impella up-

front in the Cath Lab?

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Shock Team: Lessons Learned

  • Always activate the entire multidisciplinary team
  • Initiate MCS early (and wean pressors ASAP)
  • Hemodynamic-guidance (RHC) mandatory (Cath Lab, OR, CICU)
  • Ongoing evaluation: escalation, weaning, vascular access, advanced therapies…
  • Constant vigilance (“unblinking eye”)
  • Appropriate patient selection
  • Validation, outcomes, research (become a learning organization)…

Truesdell J Invasive Cardiol 2017 INOVA –SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739 Truesdell et al Interv Cardiol 2018 Tehrani et al JACC 2019

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