Cardiogenic Shock: A Multidisciplinary Approach

Luis A Guzman MD, FACC, FSCAIDirector, Cardiac Cath Lab

Chair, SCAI International CouncilRichmond, Virginia

Society for Cardiac Angiography

and Interventions

To improve care of patients with cardiogenic shock, we have collaborated with cardiac

surgery, Interventional cardiology, and advanced CHF to develop a “Shock” response team.

The goal is to provide more consistent, comprehensive and rapid assessment, treatment and

escalation of the shock patient.

Enclosed are recommended guidelines we have developed for triggers and timing of

consultation (slides 3 and 4) as well as early assessment recommendations (slide 6).

These recommendations are to serve as triggers to identify the decompensating patient

where intervention may prevent the further development of multiorgan failure. A simple rule

is that in general, earlier is better for having multi-disciplinary involvement.

The shock team currently should be activated by the CICU team for appropriate patients.

We have developed a group “shock” page

We are initially implementing the shock team pager Monday through Friday 7a to 7p. We are

currently exploring the ability to conference in for patients who present off hours.

VCU Shock Team Program Statement

Shock Team Members

CICUTeam

(Doctor, FellowNursing staff)

Advanced Heart Failure

CT SurgeonCardiac Surgeon

Intensivist

Interventional Cardiologist

Shock Team Guidelines

Types of Patients and Entry points

• Causes

• Acute MI

• Acute systolic heart failure (myocarditis, stress CM)

• Decompensating chronic HF

• Cardiac arrest

• Entry Points for Patients

• Transfer in Shock patient

• Determine if pre-hospital notification needed

• Direct presenting patient

• ED arrival patient

• In-patient now with worsening shock

Shock Team Consultation

• Consultation

• Critical point is to be timely

• Severe shock

• Hypotensive despite 2 drips and/or support device

• on or before pt arrival

• BP stable on 2 drips and/or support device

• within 4 hr

• stable shock

• w/in 24 hr (same day if arrives before evening)

• Page sent to team members

• Meet to decide on treatment plan: impella, ECMO, etc

• Team follow up twice daily for 48 hr

Which patients should be considered for consultationSevere Shock

• MI with IABP with pressor

• MI with impella not placed for procedural support (PCI, EP)

• Acute or unknown HF status requiring 2 drips at admission

• Stable Shock pt now worsening:

• Progressive worsening in lactate (increase >2 over 4 hr), mixed venous (decrease >10% or sustained < 50% with increased lactate) or cardiac index (<2.0 with elevated lactate) despite up-titration of drips

• Failure of lactate/mixed venous to improve by (lactate by 2, MV by 10% (which ever is greater) over 4 hrs despite increase in inotropes, pressors

• Increasing inotropes to maintain perfusion (BP, lactate, mixed venous and/or cardiac output)

Initial and serial hemodynamic assessment

• Non-invasive

• Vital signs (ie hypotension, tachycardia)

• Echo

• within 2-4 hours of admission

• Assess for LV fxn, RV fxn, valve abnl, mechanical complications

• Lab values

• Serial lactate and mixed venous/MVO2

• Should be repeated q 2-4 hr initially; if stable then at 4-6 hr

• Invasive--in selected patients

• Swan (low threshold to place)

• Goal—identify and treat patients when in LV failure state (hemodynamic shock) prior to progressing to hemo-methabolic shock

Quality Assurance Process

• Feedback is a major component of success

• Bi-Weekly or Monthly Reports

• Internal Review at Cath or CICU Conference

• Inter-Department Review

• Benchmarking with national registries

Cardiogenic Shock Team Approach

30

35

15

10 10

0

10

20

30

40

50

AMI CHF Post Cardiac Arrest Myocarditis Other

Cardiogenic Shock Etiology

VCU Cardiogenic Shock Experience

Case # 1

61yo AAM w/ PMH notable for EtOH abuse, tobacco use d/o, and HTN who had a witnessed

cardiac arrest on 7/20/18 w/ agonal respirations & VF as first noted rhythm and ultimately

achieved ROSC (after CPR ~20min by family + >17min by EMS, as well as Epi x3, Amio

300mg, & shock x3) and then had EKG showing inferior MI w/ complete heartblock &

cardiogenic shock,

Taken to the Cath Lab.

Mean BP 60 mmHg with Dobutamine, Neosynephrine and Epinephrine

External Pacing dependent

Case # 1

61yo AAM w/ PMH notable for EtOH abuse, tobacco use d/o, and HTN who had a witnessed

cardiac arrest on 7/20/18 w/ agonal respirations & VF as first noted rhythm and ultimately

achieved ROSC (after CPR ~20min by family + >17min by EMS, as well as Epi x3, Amio

300mg, & shock x3) and then had EKG showing inferior MI w/ complete heartblock &

cardiogenic shock,

Taken to the Cath Lab.

Mean BP 60 mmHg with Dobutamine, Neosynephrine and Epinephrine

External Pacing dependent

Temporary PM placed

Femoral angiography performed to determine if candidate for LVAD

Impella CP placed

Coronary Angiography performed. Occluded Prox RCA. No left system issues

Successful PCI w/ DES to RCA

Arctic Protocol initiated in Cath Lab.

Serum Lactate first 24-48 hrs

15

10

5

No urinary output. Creatinine 1.7 increased to 5.0 in first 24 hrs. Need dialysis

Shock Team Called at 6 hrs from PCI and following morning.

Escalation or not? If yes. Which device. ECMO or Impela RV

CO: Require 7 l of IV fluid in first 24 hrs to maintain CO and MAP

Lactate post PCI: 12. Then 9 Then 7 at 6 hrs 6.7

6 hrs post: CVP 12-15 MAP 70-80 CO 3.0-4.0 l/min CI 1.5-2.1

12 hrs post: CVP 12-15 MAP 70-80 CO 5.0-6.0 l/min CI 2.9-3.4. Decrease Drug

support DC epinephrine. Neo and dobutamine in lower dose

Since PAPI was > 1.0, PCO 1.0 and lactate was trending down, it was considered to

continue with LV support

Neuro evaluation to determine brain status

Day 3.

Arctic Protocol stopped

Patient fully responsive

CO and Hemodynamics stable with minimal Inotropic and Vasopressors

Impela at P2. patient remained stable

Impela weaning and removed

Serum Lactate and Liver Function

15

10

5

400

300

200

1) Inferior STEMI, complicated by VF cardiac arrest and cardiogenic shock: s/p DES to RCA on 7/20.

Initially w/ complete heart block requring transvenous pacing. pacemaker removed on 7/22.

Patient s/p ARCTIC protocol. Impela removed 7/24. Improved overall.

2) 07-26 (Day 5) Patient develops Septic Shock:

Most likely source is the lungs with bilateral basal infiltrates

Repeat CT scans on 7/28 suggested possible left lower lobe ASD and moderate volume complex abdominal fluid

AGS was already consulted. No acute surgical indications.

- Pressor support w/ NE for MAP goal > 65 mmHg. Goal CVPs 6-12. Plan to wean as tolerated.

- Cx negative. C.diff negative.

3) Hypoxic Respiratory Failure:

ventilator requirements improving with diuresis via CRRT.

- Wean vent as tolerated.

4) Pancreatitis w/ abdominal compartment syndrome and ileus:

Lipase 2339. Bladder pressures normalized. KUB with improving gas pattern and resolving ileus. CT abdomen without need

for acute surgical intervention.

5) Acute Renal Failure:

Unknown baseline Cr but patient w/ oliguric renal failure requiring CRRT this admission

- Continue CRRT w/ goal even

6) Atrial Fibrillation: evening of 7/24 patient developed Afib w/ RVR. Currently in sinus

- Decrease Amio 400mg q 8 to BID

- Continue Bival for AC

7) Anemia, Coagulopathy in the setting of DIC:

Blood counts stabilizing. DIC has resolved. Patient is s/p 8 units of PRBC, 2 units of cryo, 1 unit of FFP, and 1 dose of

platelets this admission.

Patient Outcomes

Case # 2

75 yo Filipino woman

PMH AMI 10 years ago (reportedly with full recovery and most recent EF 55%), HTN, CKD 3, OSA on

CPAP, DM, HLD, gout

Presents as a transfer from OSH for RV failure, cardiogenic shock, 3 vessel CAD, MV regurgitation.

Admitted to the OSH with complaints of dyspnea, chest pain and lower extremity edema on 4/30/18.

Symptoms reportedly started 3-4 weeks before after a long road trip to the Midwest. She was admitted and

treated for presumed PE, her VQ scan showed moderate probability. She was evaluated by cards/pulm at

OSH and found to have severe RV dysfunction with severe elevation of RVSP and RV was dilated. BNP

was >3000. Dobutamine was started, but did not help, so aquaphersis was performed to off load fluid.

While in the OSH developed acute EKG changes and increase troponin. Had LHC that showed severe 3

vessel CAD and severe pulmonary hypertension with CI and CO consistent with cardiogenic shock.

An IABP was placed for the shock and she was transferred to VCU for CABG and MVR eval.

. Admitted to CICUFollowing morning, patient develops suddenly agitation, combative. Drop in O2 sat. Requires emergent Intubation Stroke alert called. CT scan No IC bleeding No ischemic stroke

Shock team CalledCICU team CT Surgery Interventional Cardiology CHF teamRadiology Imaging. Cardiac Imaging and Perfusionist

Detailed evaluation of hemodynamics in prior 24 hrsPulmonary HTN considered more secondary to MR than recent small PE (images of V/Q scan reviewed)Echo images discussed with imaging team. Severe RV dilatation. Severe MR. Good LVF Coronary anatomy reviewed. Considered that mainly LAD disease with no clear need for other vessel revascularizationCT surgery consider that surgical mortality was above 50% (RV failure, severe pulmonary HTN, CKD, combined surgeryCHF team. Not a candidate for advance therapy

Next steps considerationRV support to improve shock and RV failure (RV Impella vs ECMO)PCI of LAD to improve LV function and septal ischemiaHybrid approach PCI to CAD followed by MV surgeryMitral clip to MV and PCI to LAD

Discharged to SNF 05-30

05/23

Case # 3

68 YOM with a h/o ICM s/p prior CABG, and severe HFrEF (40 --> 15%) with a non-

revascularizable coronary tree via LHC performed at an OSH.

Developed sudden death (presumed VT) at his Cardiologist's office. Underwent CPR,

eventual ROSC. He was intubated and placed on pressors. Initiation of hypothermia

Arrive via EMS. He is currently on dobutamine at 10 mcg/kg per minute, Levophed at

15 mcg/minute, amiodarone drip 1 mg/hour, epinephrine drip 3 mcg/minute, and

supported on ventilator. Mean BP 50 mmHg. No urinary output. Lactate 9. Cr 1.5 ALT

468 AST 449

Swan Ganz was placed

CO 2.2

CI 1.5

PCO: 0.4

PIPA: > 1.0

Bedside Echo. EF 10%. Dilated with global severe hypokinesia

Shock Team CalledCICU team; CT Surgery; Interventional Cardiology; CHF team

Main questions

Does the patient should be considered for more advanced

support?

Do we think he will be a candidate for therapy to recovery?

or it has to be bridge to advanced therapy?

If only candidate to advanced therapy, does he qualify?

Mechanical support. Which one?

Any other therapy might improve outcome?

YES (CICU team)

NO (CICU team)

YES (CICU team)

YES (CHF team)

LVAD (CTS IC)

NO (CTS IC)

CTS placed a 5.0L Axillary Impela device

Outcome next 24 hrs

Impella provides 4.0 l/minLactate decrease to < 2Good urinary outputDobutamine 10mcg/kg/min only Inotropic supportLiver function stable No signs of InfectionsAmiodarone and Lidocaine drips

Plan; Continue same tratement

LAVD Monday

Outcome following 24 hrs

Patient developed frequent episodes of recurrent VTIncrease AmiodaroneVT storm. Non responsive to any drugs

SHOCK Team Called

Discussion and Conclusions

Not a candidate for LVAD definite therapy

EP Consulted

ECMO Placed for total support

Patient taken to EP Lab for EP Ablation

Successful VT Ablation

LVAD definite therapy

Outcome following 24 hrs

Patient developed frequent episodes of recurrent VTIncrease AmiodaroneVT storm. Non responsive to any drugs

SHOCK Team Called

Discussion and Conclusions

Not a candidate for LVAD definite therapy

EP Consulted

ECMO Placed for total support

Patient taken to EP Lab for EP Ablation

Shock Team Members

CICUTeam

(Doctor, FellowNursing staff)

Advanced Heart Failure

CT SurgeonCardiac Surgeon

Intensivist

Interventional Cardiologist Other Medical Consultants

• Medical Intensivist (if CICU)• Perfusionist• Nephrologist• Electrophysiologist• Respiratory Therapist• Pharmacist• Social worker• Palliative care

Regional System of Care for Cardiogenic Shock

AHA Scientific Statement. Circulation 2017;136; e232-e268

0

10

20

30

40

50

>100 60-100 30-60 <30

Mortality

Outcomes in AMI and Cardiogenic Shock and Hospital VolumeNCDR Registry

p: < 0.05

Shaeli S et al. JAHA 2015. 4; e1462

• Prompted Revascularization

• High volume operators

• Availability of more advanced

therapies and trained personnel

• More use of Mechanical

support

Cowger J et al. JACC: Heart Failure 2017, 5;10 :700-702

Outcomes in Cardiogenic Shock in CHF pts and Hospital VolumeINTERMACS Registry

Grupo colaborativo que incluye Cardiologo UCO, Cardiologo Interventionista, Cardiologo

Insuficiencia Cardiaca, Cirujano cardiaco y Perfusionista.

Para proveer en forma mas consistente, rapida y concensuada, la evaluacion, tratamiento

inicial y progression del tratamiento de los pacientes en shock

Debe tener pre establicidas guia de tratamiento y secuencia de parametros a seguir para

rapidamente determinar la progresion clinica y terapeutica

Una meta principal es identificar parametros de descompensacion donde la intervencion

podria preveer la rapida evolucion al shock multiorganico.

Una simple regla: Mientras mas precoz la intervencion, mejor es el resultado

Ademas del team primario, es necesaria la incorporacion de otras disciplinas de acuerdo al

paciente a tratar (medico intensivista, etc)

Para garantizar el exitio, es conveniente hacer una incorporacion progresiva del programa,

con frecuentes evaluaciones y feedback

Centros especializados en pacientes con shock probablemente sean beneficiosos para

majorar el exito de tratamiento

Shock Team Program Summary

Muchas Gracias