Management of Cardiogenic Shock: How Can We Improve Outcomes?

Brian Jaski, MD, FACC, FHFSA

San Diego Cardiac Center

Sharp Memorial Hospital

October 25, 2019

2019 SCAI Clinical Expert Consensus Statement on the Classification of Cardiogenic Shock

David A. Baran MD, FSCAI (Co‐Chair); Cindy L. Grines MD, FACC, FSCAI; Steven Bailey MD, MSCAI, FACC, FACP; Daniel Burkhoff MD, PhD; Shelley A. Hall MD, FACC, FHFSA, FAST; Timothy D. Henry MD, MSCAI; Steven M. Hollenberg MD; Navin K. Kapur MD, FSCAI; William O'Neill MD, MSCAI; Joseph P. Ornato MD, FACP, FACC, FACEP; Kelly Stelling RN; Holger Thiele MD, FESC; Sean van Diepen MD, MSc, FAHA; Srihari S. Naidu MD, FACC, FAHA, FSCAI (Chair)

Baran, DA Catheter Cardiovasc Interv. 2019;94:29-37.

Traditional Definition of Cardiogenic Shock

Persistent SBP < 90 mm Hg not responsive to fluid administration alone

Secondary to cardiac dysfunction

Associated with signs of hypoperfusion of a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg

Baran, DA Catheter Cardiovasc Interv. 2019; 1

“Cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion”

Cold/wetDizzy

Traditional Definition of Cardiogenic Shock

Persistent SBP < 90 mm Hg not responsive to fluid administration alone

Secondary to cardiac dysfunction

Associated with signs of hypoperfusion of a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg

Baran, DA Catheter Cardiovasc Interv. 2019; 1

Arrest (A) ModifierCPR, including defibrillation

“Cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion”

2019 SCAI Stages of Cardiogenic ShockEndorsed by ACC,AHA, SCCM, and STS

Traditional Definition of Cardiogenic Shock

Persistent SBP < 90 mm Hg not responsive to fluid administration alone

Secondary to cardiac dysfunction

Associated with signs of hypoperfusion of a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg

Baran, DA Catheter Cardiovasc Interv. 2019; 1

Arrest (A) ModifierCPR, including defibrillation

“Cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion”

2019 SCAI Stages of Cardiogenic ShockEndorsed by ACC,AHA, SCCM, and STS

Warm/wet

BP / HR

Cold/wetDizzy

>30’ resusc.Still shock

Stage D: Deteriorating

• Patients similar to C, but are getting worse.

• These patients have failure to respond to initial interventions > 30’: 3 Domains

58 yo M high school teacher to ER with 3 week history of SOB and weakness.

Stage D: Deteriorating

• Patients similar to C, but are getting worse.

• These patients have failure to respond to initial interventions > 30’: 3 Domains

58 yo M high school teacher to ER with 3 week history of SOB and weakness.

Physical Exam: Anxious, cool extremitiesIntubated

Biochem Markers:Lactate: 4.0 Creat: 2.5Bili: 1.7NT-proBNP: 8,266

Stage D: Deteriorating

• Patients similar to C but are getting worse.

• These patients have failure to respond to initial interventions > 30’: 3 Domains

58 yo M high school teacher to ER with 3 week history of SOB and weakness.

Physical Exam: Anxious, cool extremitiesIntubated

Biochem Markers:Lactate: 4.0 Creat: 2.5Bili: 1.7NT-proBNP: 8,266

Stage D: Deteriorating

• Patients similar to C but are getting worse.

• These patients have failure to respond to initial interventions > 30’: 3 Domains

58 yo M high school teacher to ER with 3 week history of SOB and weakness.

Physical Exam: Anxious, cool extremitiesIntubated

Hemodynamics:BP 88/62, mean 74. CI: 0.84 l/min/m2PCW 31, RAP / PCW 1.07 PA 48/32, RAP 33, PAPI (PA pulse pressure/RAP): 0.48Cardiac Power Output (MAP x Cardiac output): 0.30 W

Norepinephrine 25 mcg/min.

RAP / PCW > 0.8

Key Considerations in the Diagnosis & Management of Cardiogenic Shock

Is this cardiogenic

shock?

What is the severity?

Is it predominately LV, RV, or both?

What are the support options?

Thiele et al. European Heart Journal 2005;26:1276-81.

Intra-Aortic Balloon Pump

IABP

Thiele H. Circulation. 2019;139:395–403.

IABP-SHOCK II trial: 6 year follow-up

Guidelines:IABP in AMI complicated by cardiogenic shock: Class III in Europe Class IIb in United States

“No Respect”

IABP

Thiele H. Circulation. 2019;139:395–403.

IABP-SHOCK II trial: 6 year follow-up

Guidelines:IABP in AMI complicated by cardiogenic shock: Class III in Europe Class IIb in United States

Lim HS. Shock 2018 50:167–172, 2018

Etiology of Cardiogenic Shock: Acute Myocardial Infarction (AMI, n=26) vs. End Stage Heart Failure (ESHF, n=42)

Lim HS. Shock 2018 50:167–172, 2018

AMI ESHF

LVEF (%) 25+3 vs. 13+2 p<0.001

Cardiac index (L/min/m2) 1.87+0.09 vs. 1.81+.08 NS

Mean arterial pressure (mm Hg) 58+3 vs. 57+2 NS

AMI

ESHF

Right heart Pressures

mm Hg

Etiology of Cardiogenic Shock: Acute Myocardial Infarction (AMI, n=26) vs. End Stage Heart Failure (ESHF, n=42)

Lim HS. Shock 2018 50:167–172, 2018

AMI ESHF

LVEF (%) 25+3 vs. 13+2 p<0.001

Cardiac index (L/min/m2) 1.87+0.09 vs. 1.81+.08 NS

Mean arterial pressure (mm Hg) 58+3 vs. 57+2 NS

AMI

ESHF

Right heart Pressures

mm Hg

Etiology of Cardiogenic Shock: Acute Myocardial Infarction (AMI, n=26) vs. End Stage Heart Failure (ESHF, n=42)

Metabolic

Acidosis

Meq/LAMI

ESHF

Thiele et al. European Heart Journal 2005;26:1276-81.

Axillary IABP

Axillary IABP

The Balloon pump is Dead, Long Live the balloon Pump!

SCAI Stages C-ESCAI Stages A-C

Acute MI (STEMI 78%) and PCI.

100% Impella (91.8% CP)

83% vasopressors or inotropes

20% witnessed out of hospital cardiac arrest with ROSC <

30’ 29% in-hospital cardiac arrest

10% CPR during Impella implant

Creatinine 1.8 ± 2.2 mg/dL and lactate 5.4 ± 4.4 mg/dL

Impella for Cardiogenic Shock in MI

Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.

2019;93:1173–1183.

Acute MI (STEMI 78%) and PCI.

100% Impella (91.8% CP)

83% vasopressors or inotropes

20% witnessed out of hospital cardiac arrest with ROSC <

30’ 29% in-hospital cardiac arrest

10% CPR during Impella implant

Creatinine 1.8 ± 2.2 mg/dL and lactate 5.4 ± 4.4 mg/dL

Impella for Cardiogenic Shock in MI

Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.

2019;93:1173–1183.

Acute MI (STEMI 78%) and PCI.

100% Impella (91.8% CP)

83% vasopressors or inotropes

20% witnessed out of hospital cardiac arrest with ROSC <

30’ 29% in-hospital cardiac arrest

10% CPR during Impella implant

Creatinine 1.8 ± 2.2 mg/dL and lactate 5.4 ± 4.4 mg/dL

Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.

2019;93:1173–1183.

Impella for Cardiogenic Shock in MI

Impella for Cardiogenic Shock in MI

Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.

2019;93:1173–1183.

15 (12.2% of survivors) Tx’d/Eval for durable LVAD or

transplant

3 Impella RP placed in conjunction with an Impella CP

(Bipella)

5 VA-ECMO in conjunction with Impella (ECPella)

2 Converted to VA-ECMO

1 Escalated to Impella 5.0.

1 patient temporary surgical LVAD

1 patient durable LVAD

Impella for Cardiogenic Shock in MI

Basir MB, Kapur N, O’Neil W. Catheter Cardiovasc Interv.

2019;93:1173–1183.

Repositioning Sheath

Impella CP

Fiberoptic sensor just proximal to outlet cage

Impella 5.5

https://www.elso.org/Registry/Statistics.aspx

Global Number of Centers and Cases 1990-2018

ELSO Registry: Neonatal, Pediatric, and AdultCardiac, Pulmonary, eCPR

Centers Cases5x / 10 yrs

Extra-Corporeal Membrane Oxygenator

Distal leg perfusion

Burkhoff D.J Am Coll Cardiol 2015;66:2663–74.

Greater LV contractility, vasodilation, or mechanical unloading

Heart, Lung and Vessels. 2015; 7(4): 320-326

63/720=8.8%

Circulation 2014: 130:1095-1104.Rupprecht L, Heart, Lung and Vessels. 2015; 7:320-326.

Harlequin or North-South Syndrome: Heart +/- brain hypoxemia with LV Recovery

Acute MCSEtiology

Therapy/Rx

EscalateHemodynamic insufficiency

Device complicationDurable device/Transplant

PalliatePatient/Family values

Clinical frailty

De-escalateMyocardial Recovery

Device Selection: Define Your Acute MCS Path

“Bridge to Nowhere”

Serfos, Greece

PAPI < 0.9

Vascular complicationsSystemic Inflammation

Summary:

• We don’t use hemodynamic data to guide decision-making often enough

• Match device(s) to hemodynamics/pace/etiology

• Have an exit strategy ideally before initiating acute mechanical circulatory support

• Don’t ignore the RV in shock: Impella RP vs VA ECMO for RV support

• Time matters

Management of Cardiogenic Shock: How Can We Improve Outcomes?

Brian Jaski, MD, FACC, FHFSA

San Diego Cardiac Center

Sharp Memorial Hospital

October 25, 2019