cardiogenic shock team Sandeep Nathan, MD, MSc, FACC, FSCAI - PowerPoint PPT Presentation

Key elements of a cardiogenic shock team Sandeep Nathan, MD, MSc, FACC, FSCAI Associate Professor of Medicine Medical Director, Cardiac Intensive Care Unit Director, Interventional Cardiology Fellowship Program Co-Director, Cardiac Catheterization Laboratory University of Chicago Medicine | Chicago, IL Getinge symposium | SCAI 2019 | Las Vegas

Disclosures Affiliation/Financial Relationship Company • Grant / Research Support None relevant • Consulting / Advisory Panel / Honoraria Abiomed Cardiovascular Systems, Inc Getinge Terumo Interventional Systems • Major Stock Shareholder/Equity None • Royalty Income None • Ownership / Founder None • Intellectual Property Rights None • Other Financial Benefit None 2 ML-0801 Rev A/MCV00091529 REV A

Therapeutic targets in the management of cardiogenic shock 3 ML-0801 Rev A/MCV00091529 REV A

Progression of cardiogenic shock from a hemodynamic problem to a cardiometabolic syndrome Clinical stability ECG  ’s , sxs,  cardiac Myocardial ischemia Culprit PCI biomarkers MAP, Hemodynamic Vasoactives → LV/RV LV-ESP & EDP Aortic pulse instability unloading w/pMCS pressure Pulmonary Volume overload & Escalation of pMCS / edema, BNP, Neuro  ’s, systemic hypoperfusion devices in combo? lactate ECG  ’s ,  Coronary perfusion Complete revasc? biomarkers, ventricular arrhythmias End-organ Renal & hepatic unloading, Creatinine, LFTs, lactate, renal replacement Rx dysfunction coagulopathy Death Reyentovich, A., et al. Nature Reviews Cardiology 2016. 4 ML-0801 Rev A/MCV00091529 REV A

Right ventricular failure (RVF) / RV shock • Right ventricular failure (RVF) results from any structural or functional process(es ) that decrease the RV’s ability to pump blood into the pulmonary circulation • RVF and/or RV shock are rarely seen in isolation in the critically ill patient outside of pure RV infarction • RVF is increasingly being recognized as a key contributing factor to critical illness across a variety of medical and cardiac illnesses • The addition of RVF to critical illness portends poorer outcomes although the magnitude of this negative impact remains poorly characterized • The pathophysiology of RVF, as with LVF, is complex and varied but remains less studied than LV failure 5 ML-0801 Rev A/MCV00091529 REV A

Is it really as distinct as LV- vs. RV-shock? Hemodynamically defined RV dysfunction is common in AMI-CS and is largely undetected in • the absence of invasive hemodynamic assessment Esposito M., and Kapur, N. F1000Research. 2017. Lala A, et al. J Cardiac Fail 2018;24:148 – 156. 6 ML-0801 Rev A/MCV00091529 REV A

Goals of care in cardiogenic shock Early recognition & triage Emergency medical 1 providers & primary service (CCU / CVICU) Standardized diagnostic criteria Defined classes & stages 2 3 Multimodality assessment of cardiac and end-organ function Multidisciplinary 4 Cardiogenic Shock Team: Early & continuous multidisciplinary input 5 Interventional • Cardiology Clear delineation of the initial careplan & escalation strategy 6 Advanced Heart • Failure & Transplant Early revascularization (when Appropriate selection & CV Surgery • 7 8 appropriate) early use of MCS Cardiac Critical • Care Rapid escalation (or de-escalation) of care, as required 9 Primary service Involvement of consultants & ancillary service providers 10 provider Improved survival to discharge and beyond 7 ML-0801 Rev A/MCV00091529 REV A

Goals of percutaneous circulatory support Bridge patients to • Recovery • Decision • Decrease preload • Durable VAD • • Decrease afterload Transplant Provide adequate organ perfusion • Augment cardiac and O2 delivery Support patients output / power through high-risk procedures 8 ML-0801 Rev A/MCV00091529 REV A

Establishing care pathways for cardiogenic shock 9 ML-0801 Rev A/MCV00091529 REV A

What therapies can your center deliver 24/7? • Multiple percutaneous and surgical Level 1 Quaternary centers / large support devices academic medical centers • VAD and transplant programs • Cardiac arrest & ECLS protocols • Percutaneous devices and surgical Level 2 Larger community hospitals support options Some teaching hospitals • STEMI program • No or limited percutaneous support Level 3 Smaller community hospitals devices 10 ML-0801 Rev A/MCV00091529 REV A

Level 1 or “Full - service” program • Primary management: – Advanced heart failure specialist – Interventional cardiologist / Cardiac intensivist • Device deployment / management / escalation: – Interventional cardiologist – Cardiac surgeon • Core team members: – ICU pharmacist – Perfusionist – Advanced cardiac fellows – APN / RN 11 ML-0801 Rev A/MCV00091529 REV A

Level 2 or “Mid - level” program • Primary management: – Heart failure specialist / Interventional cardiologist – (Cardiac) intensivist • Device deployment / management: – Interventional cardiologist – +/- Cardiac surgeon • Core team members: – Pharmacist – Perfusionist – APN/RN 12 ML-0801 Rev A/MCV00091529 REV A

Level 1 care for cardiogenic shock Pathway for instituting a shock program OPERATOR NURSING, TRAINING, TECH, INSTITUTIONAL EQUIPMENT & SHOCK TEAM COORDINATION & SPECIALTY- PERFUSION OF CARE INVENTORY APPROACH SPECIFIC SUPPORT & DELIVERY, ISSUES “BUY - IN” ICU CARE THROUGHPUT & LOGISTICS Clear agreement Assembly of a Key issues: Key issues: Establish initial & • repeating training Hardware between all key 24/7/365 Implanting MDs • • for nurses & techs. ownership, ratios & location, stakeholders multidisciplinary Have a clear • & location Explanting • regarding cardiogenic understanding Disposables • MDs, location & with perfusionists. indications, shock team Cath lab vs. • Train ICU nurses & timing • contraindications OR/C-arm vs. designate Bed geography • and procedure room receiving units programmatic vs. HOR? ECLS cart goals. • 13 ML-0801 Rev A/MCV00091529 REV A

Level 1 care for cardiogenic shock Key members of the shock team SUPPORTING STAFF 1. Vascular Surgery 2. Cath Lab: Nurses, SHOCK TEAM Technologists (ideally Advanced Interventional APPROACH with 1 “super - user” Heart Failure Cardiology each) 3. ICU: Nursing leadership support 4. Perfusionists Cardiovascular Cardiac Critical Assembly of a Surgery Care Specialists 24/7/365 multidisciplinary cardiogenic shock team 14 ML-0801 Rev A/MCV00091529 REV A

Level 1 care for cardiogenic shock Chain of communication within the center ED & EMS IC 15 ML-0801 Rev A/MCV00091529 REV A

Level 1 care for cardiogenic shock Chain of communication within the center HF, ICU Shock ED IC & CV team surgery decision Key issues to resolve: • Initial care plan including MCS, vasoactive support, ICU care • Identifying NOK / POA • Identifying goals of care / limitations to care • Chart out escalation plan • Decide on timing of next clinical / hemodynamic “snapshot” 16 ML-0801 Rev A/MCV00091529 REV A

Protocolizing cardiogenic shock care ML-0801 Rev A/MCV00091529 REV A

Step 1: Objectively assess, stabilize & perform complete revascularization BEST PRACTICES BEST PRACTICES Activate Cardiac Cath Lab Access: 1. Femoral arterial access using micropuncture with Access image guidance (ultrasound and/or fluoroscopy) 1 2. Angiography via 4F micropuncture dilator to confirm puncture site & vessel size Assess Assess Hemodynamics: LVEDP or PAC 3. Place appropriately sized (5 or 6 Fr) arterial Hemodynamics • If sustained hypotension (SBP < 90 mmHg) for > 30 min sheath Or 4. Obtain venous access (femoral or internal jugular) • CI < 2.2 with LVEDP or PCWP >15 mmHg, pMCS consider mechanical circulatory support If femoral arterial anatomy suitable and no contraindications, place, or escalate to (if IABP already in place), Impella 2.5 or Impella CP Begin Weaning Catecholamines* * If consistent with overall hemodynamic managemen t Yes Acute MI? No PCI: Coronary angiography Coronary Angiogram and PCI with goal of complete with PCI Reassess Hemodynamics: PAC (if not done revascularization. initially) Reassess CPO = (CO  MAP)/451 1. Hemodynamics 2. PAPi = (sPAP-dPAP)/CVP Soverow J, Lee MS. J Invasive Cardiol. 2014;26(12):659-667 CO, cardiac output; CPO, cardiac power output; dPAP, diastolic pulmonary arterial pressure; MAP, mean arterial pressure; PAC, pulmonary 18 arterial catheter; PAPi, pulmonary artery pulsatility index; RA, right arterial pressure; sPAP, systolic pulmonary arterial pressure. ML-0801 Rev A/MCV00091529 REV A