2/19/2020 HEMODYNAMIC SUPPORT IN ACUTE CARDIOGENIC SHOCK Catherine T. Prince, DO, PhD, MPH, FACC Northstate Cardiology Consultants 1 • 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 HPI chest pain • EKG showed anterolateral/inferior STEMI • Transferred to Enloe for cath/PCI and was hemodynamically stable upon arrival to ED 2 INITIAL DATA Pre procedure vitals HR – 79 BP – 113/76 RR - 20 SPO2 – 95% 3 1
2/19/2020 DIAGNOSTIC ANGIOGRAM 4 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 5 IMPELLA PRE-PCI 6 2
2/19/2020 DIAGNOSTIC ANGIOGRAM 7 • 6 Fr right radial arterial access • 6 Fr EBU 4.0 guiding catheter • BMW 0.018” to proximal LAD INTERVENTIO • Pre dilation of the proximal LAD with a 2.5 mm x 15 mm Sprinter balloon NAL • 2 nd BMW 0.018” to LCx STRATEGY • 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 8 INTERVENTION 9 3
2/19/2020 INTERVENTION 10 INITIAL DATA Pre procedure vitals Labs GTTS HR – 79 CK-Total - 466 No GTTS upon arrival to CCL BP – 113/76 Troponin - 384 RR - 20 SPO2 – 95% 11 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 12 4
2/19/2020 • 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 SUMMARY • 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 13 14 15 5
2/19/2020 16 17 18 6
2/19/2020 19 20 21 7
2/19/2020 22 23 24 8
2/19/2020 25 26 27 9
2/19/2020 28 NON-ISCHEMIC SHOCK 29 HPI Sudden onset of bilateral paresthesias • • 50 y/o WM in feet • PMH • Presented to the ED with evidence of • hyperlipidemia septic shock • Hypertension • Severe hypotension with BP in the 70s • PSH while in the ED • Fracture surgery • Admitted to the ICU and started on pressors overnight • Social History • Alcohol use ~14 beers/week • Echo revealed a LVEF of ~20% with global hypokinesis and • Former smoker • Past history of marijuana use • No prior history of CAD 30 10
2/19/2020 INITIAL DATA Pre procedure vitals Labs GTTS HR – 140 WBC – 35.5 Levophed BP – 86/57 BUN - 40 Vasopressin RR – 35 Creatinine – 2.9 SPO2 – 100% Worsening acidosis 31 ECHOCARDIOGRAM 32 • 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 ASSESSMENT • ABG showed worsening acidosis, patient was intubated • It was determined that the patient was suffering from biventricular failure that required mechanical circulatory support 33 11
2/19/2020 • 50 y/o WM patient presented to the ED in septic shock • The patients condition worsened in the ICU SUMMARY • 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 34 DIAGNOSTIC ANGIOGRAM 35 RIGHT HEART CATHETERIZATION • RA – 20 • CPO – 0.71 Watts • RV – 43/13 (23) • PAPi – 0.67 • PA – 39/27 (33) • PCWP – 25 • Fick CO – 4.26 L/min • Fick CI – 1.78 L/min/m2 36 12
2/19/2020 IMPELLA PLACEMENT 37 38 39 13
2/19/2020 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 40 41 42 14
2/19/2020 43 44 IMPELLA SUPPORTED HIGH RISK PCI 45 15
2/19/2020 • 93 y/o WM • CC of stable angina • NKDA • Past Medical History HPI • CAD • Prior stents in 1995 • Hypertension • Dyslipidemia • TIAs • Severe AS 46 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 47 SEVERE AORTIC STENOSIS 48 16
2/19/2020 DIAGNOSTIC ANGIOGRAM 49 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 50 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 51 17
2/19/2020 IMPELLA PRE-PCI 52 INTERVENTION 53 • 8 Fr EBU 3.5 guiding catheter • BMW 0.014” to LCx • 2 nd BMW 0.014” to the LAD INTERVENT • Predilation of the Ostial LCx with a 2.5mm x 12mm IONAL balloon STRATEGY • Predilation of the Ostial LAD/Distal LM with a 3.0mm x 12mm balloon 54 18
2/19/2020 • 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 INTERVENT • dLM/Ostial LAD was then post dilated with a 4.0mm IONAL NC balloon STRATEGY • Whisper 0.014” guidewire was used to cross the CONTD. 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 55 INTERVENTION 56 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 57 19
2/19/2020 58 59 60 20
2/19/2020 61 62 63 21
2/19/2020 64 65 66 22
Recommend
More recommend
