door to hemodynamic support: developments in cardiogenic … shock.pdfrationale for shock team •...

Door to Hemodynamic Support:

Developments in Cardiogenic Shock

Alexander (Sandy) Dick, MD

ACC Rockies, 2019

Disclosures

• None

What is the Level of Evidence to Change Practice?

Objectives

• Review the definition and physiology of cardiogenic shock

• Review current trends in cardiogenic shock epidemiology

• Review the role of mechanical support in cardiogenic shock– Intra-aortic balloon pump

– Impella

– ECMO

• Integrate cardiogenic shock and MCS into systems of care

Definition of Cardiogenic Shock

• Decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.

Van Diepen et al. Circulation. 2017.

• 28% of CS with MI will be cold and dry

• Warm and wet due to SIRS-like response

• 5% have decreased organ perfusion despite SBP >= 90 mmHg

• 5% have RV infarction phenotype (low CI, low PCWP)


Three High

Dose

2% 3% 7.5%21%

42%

80%

Pre-Shock Profound ShockShockNo Hemodynamic

Support

Needs Partial

Hemodynamic Support

Needs Full

Hemodynamic Support

Mortality Risk with Inotrope Dosing

Adapted from Samuels LE et al, J Card Surg.

1999 Jul-Aug;14(4):288-93

Cardiogenic Shock and Drug TherapyAdapted from Samuels LE et al, J Card Surg. 1999;14(4):288-93

Trends in Cardiogenic Shock

Kolte D. J Am Heart Assoc. 2014;3(1):e000590.

Management of Cardiogenic Shock with MCS

Role of MCS in Cardiogenic Shock• Bridge to recovery

• Bridge to bridge

• Bridge to transplant

• Bridge to diagnosis

• Bridge to decision

• Temporary versus durable

Atkinson et al. JACC. 2016

IABP - Function

• Rapidly inflates in diastole, displacing balloon volume and increasing diastolic blood pressure

• Rapidly deflates in systole, reducing afterload

IABP Shock II

Thiele et al. NEJM. 2012

Thiele et al. NEJM. 2012

Thiele et al. Circulation. 2018

IABP – Roles

• Has recently been downgraded in ESC and AHA guidelines• ESC Guidelines: IIIA• AHA NSTEMI Guidelines: IIIA

• Use has declined as a result

• Still has a role to play• Mechanical complications: severe MR or VSD• LV unloading in ECMO patients?

Impella

Seyfarth et al. JACC. 2008

Ouweneel et al. JACC. 2016

Infarct Size with Impella Support

ControlMeynes, JACC 2003

The University of Ottawa Heart Institute (UOHI) - SHOCK TEAM

SCAI SHOCK – October 2018On Behalf of the UOHI Shock Team –

Derek YF So, MD FRCPC FACC

Associate Professor,

Program Director, Adult Interventional Cardiology

Special Thanks: Drs. Jordan Hutson, Sharon Chih, Sophie De Roock, Aun Yeong

Chong, Michel Le May

Rationale for Shock Team• Evidence and M+M rounds identifying delay in treatment and

high mortality of young shock patients

• Proven track record in regional STEMI program• Primary PCI• Pharmaco-invasive program• ROSC program

• Need for handling of cardiogenic shock patients beyond those secondary to MI alone.

• Rather than an algorithm alone, we required a comprehensive multi-disciplinary team based program

Our protocol was developed through:

• review of local data and systems capabilities

• evidence in the literature

• discussions with key stakeholders

Shock Team Roles

SHOCK TEAM

Advanced Heart Failure

Intensive Care

Interventional Cardiology

Cardiac Surgery • Define coronary anatomy

• Percutaneous coronary revascularization

• MCS insertion

• Percutaneous TAVI/Mitral Clip

• CHIP Program

• E-CPR Program

• Haemodynamic optimization

• MCS management

• Metabolic optimization

• Pulmonary stabilization

• Renal stabilization

• Nutrition

• Sepsis/infectious issues

• Mobilization

• MCS insertion

• Surgical coronary revascularization

• Valve surgery

• Evaluate candidacy for advanced HF therapies (Durable VAD/HTx)

• Hemodynamic optimization

• MCS management

• Evaluate candidacy for advanced HF therapies (Durable VAD/HTx)

• Assist with end-of-life decision-making

Nursing, Perfusion, Respiratory Therapy, Physiotherapy, Palliative Care

Innovations of the Program• Smart phone-based app to enable “virtual” team discussion

• Dual operators for MCS insertion to improve efficiency, maximize application of cardiac sub-specialty skillset and increase operator experience

• Expedite decision for MCS, including defining: i) guide for device choice, ii) roles for physician teams based on the device, iii) location for implant and iii) mobilization of allied teams to accommodate patient post implant.

• Daily multi-disciplinary Shock Team rounds to expedite decisions pre/post MCS, including: decisions for LVAD and transplant.

• Timely review of all cases (within 1 month) by Quality and Outcomes officer to enable systematic evaluation, review and quality improvement; Feedback with quarterly team review of all cases.

Treatment and Outcomes

0

10

20

30

40

50

Code ShockControl

P=0.08

MCS Support

P=0.32

P=0.10

P=0.99

0 9 0 1 8 0 2 7 0 3 6 0 4 5 0 5 4 0

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

S u rv iv a l

D a y s

Pe

rce

nt

su

rviv

al

p = 0 .0 3 8

T re a tm e n t: C O D E S H O C K

C o n tro l: H is to r ic a l c o h o rt

Code Shock% Survival

Control% Survival

P-value

7-days 88% 74% 0.10

30-days 74% 64% 0.40

Discharge 70% 56% 0.21

Overall Survival

Conclusions: UOHI Shock Team

• Accelerated “team approach” for discussion, decision making and therapy

• Protocols for temporary MCS: types of MCS and location for implants, location recovery

• Long-term decisions for durable MCS / Transplant

• Trends for improvement in outcomes with UOHI Code Shock Team protocol

Pathophysiology

Decreased myocardial contractility leading to deleterious spiral:Decreased cardiac output

Low blood pressure

Further coronary ischemia

Further reduction in cardiac output

Adverse compensatory mechanisms

Vasoconstriction

Fluid and sodium retention

Inflammation and SIRS

Decreased catecholamine sensitivity

Lessons Learned..

Basir M, Schreiber T, Grines C, et al. Effect of Early Initiation of Mechanical

Circulatory Support on Survival in Cardiogenic Shock. Am. J. of Cardiology, 2016

<75 mins >4 hrs

Circulatory Support

Systemic Perfusion

Ventricular Support

LV/RV Unloading

Coronary Perfusion+ +

Mean Arterial PressureLV-ESP & EDP

Ao Pulse PressureMAP - LVEDP

Time in Cardiogenic Shock

Rx: Multi-organ SupportUnloading, Ventilator, CVVHD

Hemo-Metabolic Problem

Rx: Hemodynamic SupportCirculatory and Ventricular

Hemodynamic Problem

LactateCreatinine

Vent TachycardiaBNP

ST-ChangesTroponin/CKMb

Recovery Death

Lessons Learned..

CGS Therapies – Practical Tips

1. Let the Hemodynamics Guide You(Early PA Catheter Implantation)

2. Inotropes and Vasopressors have a COST(Monotherapy only in Early Shock)

3. There is Nothing to be Gained by Waiting in CGS (Consider Early/Pre-PCI MCS Implant)

Lessons Learned..

Basir M, Schreiber T, Grines C, et al. Effect of Early Initiation of Mechanical

Circulatory Support on Survival in Cardiogenic Shock. Am. J. of Cardiology, 2016

<75 mins >4 hrs

Circulatory Support

Systemic Perfusion

Ventricular Support

LV/RV Unloading

Coronary Perfusion+ +

Mean Arterial PressureLV-ESP & EDP

Ao Pulse PressureMAP - LVEDP

Time in Cardiogenic Shock

Rx: Multi-organ SupportUnloading, Ventilator, CVVHD

Hemo-Metabolic Problem

Rx: Hemodynamic SupportCirculatory and Ventricular

Hemodynamic Problem

LactateCreatinine

Vent TachycardiaBNP

ST-ChangesTroponin/CKMb

Recovery Death

Lessons Learned..

CGS Therapies – Practical Tips

1. Let the Hemodynamics Guide You(Early PA Catheter Implantation)

2. Inotropes and Vasopressors have a COST(Monotherapy only in Early Shock)

3. There is Nothing to be Gained by Waiting in CGS (Consider Early/Pre-PCI MCS Implant)

Historical Perspectives

Pre-revascularization era

• MI-associated CS: mortality >80%

• Killip IV CS associated: mortality 81%

• Diamond-Forrester Swan Classification IV (PCW >18, CI <2.2): mortality 51%

Revascularization ERA

• Fibrinolysis: limited association with improvement in outcomes

• Early revascularization with PCI/CABG

• SHOCK trial

• No reduction in mortality at 30 days

• Mortality reduced at 6 and 12 months, persisted at long term follow-up

Yannopoulos et al. JACC.

2017

Mandawat et al. Circ

Cardiovasc Interv. 2017

Systems of Care

Shock Team Co-leads

ADVANCED HEART FAILURESharon ChihLisa MielniczukEllamae StadnickRoss DaviesMariana Lamacie

CARDIAC SURGERY

Munir BoodhwaniMarc RuelDavid GlineurVincent ChanFraser Rubens

INTENSIVE CARE

Bernard McDonaldBrock WilsonRyan MahaffeyRobert ChenSean DickieSophie De Roock

INTERVENTIONAL CARDIOLOGYDerek SoAun Yeong ChongChristopher GloverMichel Le May

The team comprises over 20 dedicated physicians, supported by allied health teams including nursing, perfusion, respiratory therapy and physiotherapy.

What next?• Who gets consulted in

your hospital on these patients?

• Interventional• HF/Transplant• Surgery/Anesthesia/ICU• All?• No routine protocol

• Decision by team was temporary support with decision on long-term plan pending

What device?

CARDIOGENIC SHOCK: INTERMACS 1 or 2

RVRAP >14

PCWP <18

PAPi <1.5

Bi-VRAP >14

PCWP >18

PAPi <1.5

Cardiac Arrest

Protek Duo/RP Impella VA ECMO

Poor Oxygenation

LVRAP <14

PCWP >18

PAPi >1.5

Impella

• RA: 6

• PCWP:29

• PAPi: 5

• CPO: 0.50

Who implants?

• Intervention only

• Surgery only

• Variable

Impella Size

• 2.5 L

• CP

• 5L

Code Shock Program –Preliminary Data

• Code Shock Cohort (N=43) (4/2016 – 12/2017) vs. Historical Cohort (1/2015 – 3/2016) (N=39)

All n = 82

Code Shock n = 43

Control n = 39

P value

Age 60.0 (44.0-66.0) 55.0 (42.0-64.0) 65.0 (57.0-70.0) 0.007 Male 61 (74) 34 (79) 27 (69) 0.308 New heart failure diagnosis 37 (45) 26 (60) 11 (28) 0.003 Heart failure etiology

Acute myocardial infarction Acute myocarditis Tachycardia-induced Dilated cardiomyopathy Ischemic cardiomyopathy Other

11 (13)

5 (6) 10 (12) 27 (33) 18 (22) 8 (10)

5 (12) 5 (12) 7 (16)

14 (33) 5 (12) 7 (16)

6 (15) 0 (0) 3 (8)

13 (33) 13 (33)

1 (3)

0.749 0.056 0.318 0.941 0.031 0.060

Biochemistry, mmol/L Lactate Creatinine Aspartate aminotransferase

2.7 (1.8-4.9) 140 (98-220)

127 (37-1735)

2.8 (1.8-5.0) 139 (97-205)

172 (49-3180)

2.3 (1.8-4.3) 143 (98-266) 94 (31-607)

0.924 0.373 0.182

Cardiac function LVEF, % Moderate-severe RV

20 (15-27)

44 (56)

18 (15-25)

24 (56)

20 (15-28)

20 (56)

0.268 0.982

Future Challenges for Interventional Perspective

1. Increase upfront use of MCS at STEMI with shock

• Development of algorithm

• Funding of MCS devices

• Care in CICU

2. Regional hub and spoke model

Van Diepen et al. Circulation. 2017; 136 e232-268

Atkinson et al. JACC. 2016

Thiele et al. Circulation. 2018

The Simple Goals of Cardiogenic Shock Therapy

• In patients with severe hemodynamic embarrassment, what are the treatment goals?

1. “Feed the Body”

2. “Rest the Heart and Allow for Recovery”

Rest is the Road to Recovery

• Myocardial rest is:

“Maintenance of hemodynamics while minimizing myocardial work” – Heart Failure Cardiologist“Tipping the oxygen supply-demand equation away from demand by modifying filling dynamics and LVEDD” – Echocardiologist

“Uhh… Stent?” – Interventional Cardiologist

“Reduction in the myocardial oxygen consumption as demonstrated by a decrease in myocardial Total Mechanical Work (PVA) and heart rate with simultaneous LV unloading

and hemodynamic support”– Interventional Hemodynamicist

door to hemodynamic support: developments in cardiogenic … shock.pdfrationale for shock team •...

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