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

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

Cardiogenic Shock Mortality Killip 1967 CULPRIT-SHOCK 2017 SHOCK 1999 • 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

Clinical Objectives in Shock ? Percutaneous VAD PCI SIRS Free radical defense, Inhibitors, Antibodies, ??? Reduce Myocardial Interrupt SIRS Maintain Vital Organ Increase Coronary Oxygen Demand Response Perfusion Flow Kohsaka et al Arch Intern Med 2005 Kapur et al www.acc.org 2016 Johansson et al Crit Care 2017

Is There A “Goldilocks” Device? • Easy, percutaneous implantation • Effective, reliable circulatory support • Maintain systemic perfusion pressure • Ventricular unloading • Easy to manage post- insertion • Low complication ( Bi-Pella /EC-Pella) rates (limb ischemia, stroke, hemolysis) Minimal benefit in Labor No LV unloading clinical trials intensive Seyfarth et al JACC 2008 Rihal et al Catheter Cardiovasc Interv 2015 Thiele Lancet 2013 Van Diepen et al Circulation 2017 Cheng Ann Thorac Surg 2014 Mandawat et al Circ Interventions 2017 Kapur et al www.acc.org 2016

The “NCSI Argument”… • 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… 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

Team of Teams • • • EMS Triage Decrease time to intervention • • Emergency Medicine Communications • “What if you could combine the adaptability, agility, and • Initiate advanced therapies • • Interventional Cardiology Transport cohesion of small teams with the power and resources of a giant early • • Echocardiography 24/7 on-site personnel • organization?” Full-spectrum management • • Cardiothoracic Surgery Decision-making • “Leaders looked at the best practices of the smallest units and • • Perfusionist Leadership found ways to extend them to thousands of people on three • • Critical care Protocols continents” • • Advanced Heart Volume/Expertise • “The task force became a ‘team of teams’ – faster, flatter, more Failure/Transplant • Quality flexible ” • Full ancillary services • Plug-and-play options • Telemedicine • 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

Tiers of Care… • What “level” are you? • Are you part of a larger Level I, II, III “network (team)”? van Diepen et al Circulation 2015 Kern et al Circ Journal 2014 Nathens et al Lancet 2004 Tchantchaleishvili et al JAMA Surgery 2015 Graham et al Circulation 2012 Rab et al JACC 2018

INOVA: In The Beginning… 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: Our Journey…

• “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

• 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

• 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

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

After Action Reviews… • 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 organization… U.S. Army TC 25-20 1993 Doll et al Circ Outcomes 2017 Truesdell et al Interv Cardiol 2018

INOVA: Performance Metrics… Tests of Change Responsible Dates of test Results Cardiac Access, July 2017 Number of CS team activations were 1. Adoption of one-call Johnny Ellis Dec 2017 measured and all calls were recorded to activation July 2018 assess multidisciplinary team participation . Dec 2018 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. CS Team July 2017 Right heart catheterization performed: 2. Adoption of algorithm Dec 2017 Jan- Jun 2017: 70% of patients with CS July 2018 Jul- Dec 2017: 82% of patients with CS Dec 2018 Jan- Jun 2018: 97% of patients with CS Jul- Dec 2018- 99% of patients with CS : CS Team July 2017 30 Day survival increased every 6 months: 3. Effectiveness of overall Dec 2017 Jan- Jun 2017: 55% survival strategy July 2018 Jul- Dec 2017: 62.5% survival Dec 2018 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: Results… AMI ADHF 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

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

• Antero-lateral STEMI • Culprit proximal LAD thrombotic occlusion • OM1 ostial 70% stenosis • RCA minimal disease

• 3.5mm x 32mm DES • Long case, recurrent slow reflow • “Successful” PCI

• EF 25%, anterior/apical dyskinesis • IABP 1:1, Dopamine “support” initiated for hypotension

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

Hemodynamics (next AM) CPO 0.4 (not calculated) HR 90s/Sinus PAPi 1.0 (not calculated) CVP 17 PA 36/19 • Rising Lactate, Cr, LFTs • Inter-facility transfer to CICU Dopamine 20 mcg Levophed 20 mcg Personal Biases: IABP 1:1 - Pressors are poison… - ”Too high” MAP goals lead to harm… Fick CI 1.7

Windows Of Opportunity… • 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

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