cardiogenic shock: “teams of teams”€¦ · cardiogenic shock mortality • persistently high...

Cardiogenic Shock:“Teams of Teams”

Alexander G. Truesdell, MDVirginia Heart

Falls Church, Virginia, USA

@agtruesdell

Consultant, Abiomed Inc.

Speakers Bureau, Abiomed Inc.

Disclosures

• Background

• Managing Cardiogenic Shock in 2019

• Paradigm Shift: “S2S”

• Identifying “Best Practices”

• Teamwork Makes the Dream Work

Objectives

Cardiogenic Shock Mortality

• 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 2016Hochman et al NEJM 1999 Scholz et al Eur Heart J 2018Samuels et al Journal of Cardiac Surgery 1999 Krishnan et al Int J Cardiol 2017Goldberg et al NEJM 2001 Thiele et al NEJM 2017Goldberg et al Circulation 2009 Obling et al Eur Heart J Acute Cardiovasc Care 2018Kunadian et al JACC Interv 2014 Strom et al Eurointervention 2018Shacadia et al JACC Interv 2018 Wong et al Can J Cardiol 2019

Killip 1967 CULPRIT-SHOCK 2017SHOCK 1999

Kohsaka et al Arch Intern Med 2005Kapur et al www.acc.org 2016Johansson et al Crit Care 2017

Clinical Objectives in Shock

Maintain Vital Organ Perfusion

Reduce Myocardial Oxygen Demand

Increase Coronary Flow

Interrupt SIRSResponse

SIRS

Free radicaldefense,

Inhibitors,Antibodies,

???

Percutaneous VAD PCI ?

http://www.acc.org/

Seyfarth et al JACC 2008Thiele Lancet 2013Cheng Ann Thorac Surg 2014Kapur et al www.acc.org 2016

Is There A “Goldilocks” Device?

Minimal benefit in clinical trials

No LV unloadingLaborintensive

(Bi-Pella/EC-Pella)

• Easy, percutaneous implantation

• Effective, reliable circulatory support

• Maintain systemic perfusion pressure

• Ventricular unloading

• Easy to manage post-insertion

• Low complication rates (limb ischemia,

stroke, hemolysis)

Rihal et al Catheter Cardiovasc Interv 2015Van Diepen et al Circulation 2017Mandawat et al Circ Interventions 2017

Keeley et al Lancet 2003Tchantchaleishvili et al JAMA Surgery 2015Shavadia et al JACC Interv 2018Wong et al Can J Cardiol 2019https://www.henryford.com/cardiogenicshock

• 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…

The “NCSI Argument”…

Team of Teams• EMS

• Emergency Medicine

• Interventional Cardiology

• Echocardiography

• Cardiothoracic Surgery

• Perfusionist

• Critical care

• Advanced Heart

Failure/Transplant

• Full ancillary services

• Telemedicine

• Triage

• Communications

• Transport

• 24/7 on-site personnel

• Decision-making

• Leadership

• Protocols

• Volume/Expertise

• Quality

• Plug-and-play options

• Outcomes

• Research

Haft et al Ann Thorac Surg 2010Doll et al Catheter Cardiovasc Interv 2015McChrystal et al Team of Teams 2015Atkinson et al JACC: Interv 2016Truesdell et al Interv Cardiol 2018

• Decrease time to

intervention

• Initiate advanced therapies

early

• Full-spectrum management

• “What if you could combine the adaptability, agility, and cohesion of small teams with the power and resources of a giant

organization?”• “Leaders looked at the best practices of the smallest units and

found ways to extend them to thousands of people on three continents”

• “The task force became a ‘team of teams’ – faster, flatter, more flexible”

van Diepen et al Circulation 2015Nathens et al Lancet 2004Graham et al Circulation 2012

• What “level” are you?

• Are you part of a larger Level I, II, III “network (team)”?

Kern et al Circ Journal 2014Tchantchaleishvili et al JAMA Surgery 2015Rab et al JACC 2018

Tiers of Care…

INOVA–SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739Tehrani et al JACC 2018Truesdell et al Interv Cardiol Rev 2018 Tehrani et al JACC 2019Rosner et al IAMS 2019

INOVA: In The Beginning…

https://clinicaltrials.gov/ct2/show/NCT03378739

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/NCT03378739Tehrani et al JACC 2018Truesdell et al Interv Cardiol 2018 Tehrani et al JACC 2019Rosner 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.)



• 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…



• Bedside or “Virtual” consultation

• Real-time LVEDP, MAP, CPO, Flow (to integrate with Swan)

• Support, weaning, escalation, trends…

• Real-time remote data access/viewing

Smar

tAss

ist

Imp

ella Co

nn

ect

After Action Reviews…

U.S. Army TC 25-20 1993Doll et al Circ Outcomes 2017Truesdell et al Interv Cardiol 2018

• 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…

Tests of Change

Tests of Change Responsible Dates of test Results

1. Adoption of one-call activation

Cardiac Access, Johnny Ellis

July 2017Dec 2017July 2018Dec 2018

Number of CS team activations were measured and all calls were recorded to assess multidisciplinary team participation. 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.

2. Adoption of algorithm CS Team July 2017Dec 2017July 2018Dec 2018

Right heart catheterization performed:Jan- Jun 2017: 70% of patients with CSJul- Dec 2017: 82% of patients with CSJan- Jun 2018: 97% of patients with CSJul- Dec 2018- 99% of patients with CS

3. Effectiveness of overall strategy

CS Team July 2017

Dec 2017July 2018Dec 2018

30 Day survival increased every 6 months:

Jan- Jun 2017: 55% survivalJul- Dec 2017: 62.5% survivalJan- Jun 2018: 76.5% survival

Jul- Dec 2018: 72.8% survival


INOVA: Performance Metrics…

:



INOVA: Results…

AMI

ADHF


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)HR 110s/Sinus

SBP 90s

RA 10

RV 30/8

PA 28/15

PCW 18

LVEDP 28

PA Sat 67% (FiO2 100%)

CI 2.0 (not calculated in Lab)

CPO 0.4 (not calculated in Lab)

PAPi 1.3 (not calculated in Lab)

Dopamine 20 mcg

• Admit to ICU

Hemodynamics (next AM)HR 90s/Sinus

CVP 17

PA 36/19

Dopamine 20 mcg

Levophed 20 mcg

IABP 1:1

Fick CI 1.7

CPO 0.4 (not calculated)

PAPi 1.0 (not calculated)

• Rising Lactate, Cr, LFTs

• Inter-facility transfer to CICU

Personal Biases:

- Pressors are poison…

- ”Too high” MAP goals lead to harm…

• Progression from hemodynamic problem…to “hemo-metabolic” problem…

• Intervene…before…reversible becomes irreversible…

Ouweneel et a JACC 2016Esposito et al F1000 Research 2017Kapur et al Interv Cardiol Clin 2017Lawler et al JHLT 2018 Vallabhajosyula et al JACC 2019

Windows Of Opportunity…

• 47 year-old 80kg man

• Occlusive IABP (“Shock” vessels with high-dose pressors)

Multi-disciplinary Decision-Making

Impella

ECMO(17 Fr A, 25 Fr V)

EC-Pella

Karaltolios et al Int J Cardiol 2016Lim Artif Organs 2017Mourad et al ASAIO Journal 2017Nalluria et al J Exp Rev Med Device 2017

Pappalardo et al Eur J Heart Fail 2017Lala et al J Cardiac Fail 2018Overtchouk et al Eurointervention 2018Patel et al ASAIO Journal 2018

• Progression of failure: from LV to BiV…

• > 24 hours since initial insult

• Rising Cr, LFTs

• Worsening oxygenation

• IV, CT Surgery, CCU, CritCare, HF

• Bi-Pella vs. EC-Pella?

Pappalardo et al Eur J Heart Fail 2017Russo et al JACC 2019Dzavik et al JACC 2019

• Concomitant tx with VA-ECMO and Impella (LV Unloading) may improve outcomes compared with VA-ECMO alone…

• ? also shorten ECMO duration…

• EC-Pella

• ECMO decannulated after 3 days

• #PercAx Impella removed after 6 days

• Milrinone weaned off after 8 days

Hospital Course

• Normalized LV systolic function

• Fick CI 4.3 L/min

• Off all support

Final Status

• Discharged to home on HD #28

• Back to work full-time

• What might this have looked like…if…patient had received Impella up-front in the Cath Lab?

Shock Team: Lessons Learned

• Always activate the entire multidisciplinary team

• Initiate MCS early (and wean pressors ASAP)

• Hemodynamic-guidance (RHC) mandatory (Cath Lab, OR, CICU)

• Ongoing evaluation: escalation, weaning, vascular access, advanced therapies…

• Constant vigilance (“unblinking eye”)

• Appropriate patient selection

• Validation, outcomes, research (become a learning organization)…

Truesdell J Invasive Cardiol 2017INOVA –SHOCK Registry: https://clinicaltrials.gov/ct2/show/NCT03378739Truesdell et al Interv Cardiol 2018Tehrani et al JACC 2019


cardiogenic shock: “teams of teams”€¦ · cardiogenic shock mortality • persistently high...

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