Case Review, Impella Education, AMI Cardiogenic Shock
Fellows Course: ICU & Device Management
Timothy Smith, MD, FACC, FSCAI, discusses the importance of the cardiovascular ICU (CVICU) and device management for patients with cardiogenic shock supported with the Impella® heart pump. Dr. Smith is director of the CVICU at The Christ Hospital in Cincinnati, Ohio. This discussion was part of Abiomed’s MCS & Complex Coronary Intervention virtual fellows course held on September 26, 2020.
Dr. Smith begins with a patient case highlighting escalation of therapy and device management. The patient is an 88-year-old male who flew home early from vacation after experiencing worsening chest pain and dyspnea. He had severe aortic stenosis and decompensated heart failure. An IABP was placed, and he was admitted to the CVICU. His urine output, blood pressure, and oxygen status continued to decrease, Levophed and dobutamine were initiated, and he was intubated. He returned to the cath lab, the IABP was removed, and his hemodynamics improved markedly when an Impella CP® was placed. Four days later he underwent TAVR and was discharged home.
“In the example of this patient’s case,” Dr. Smith explains, “the key to early survival is simply early recognition. If one recognizes, suspects, confirms, and then activates or treats based on parameters of shock, outcomes and mortality tend to improve.”
Dr. Smith discusses current shock care trends, noting that more cases of shock are now being managed in community hospitals, although many of these smaller hospitals have limited resources and expertise for managing shock. Dr. Smith emphasizes the importance of regionalized hub and spoke shock management. “If these patients have cardiogenic shock and are at outlying hospitals without PCI capability, they should be transferred to a facility where they have PCI capability as well as shock capacity.”
Dr. Smith describes the importance of The Christ Hospital shock team, which includes cardiovascular critical care, interventional cardiology, heart failure, cardiac surgery, and the CVICU staff as well as other specialties. He discusses the necessity of a skilled cardiac ICU and cardiac intensivists to handle issues that can lead to detrimental outcomes if not addressed. Some of the strategies he discusses include:
- Limb ischemia can be avoided by measures such as routinely checking Doppler pulses, minimizing vasopressors, and developing an antegrade sheath flushing protocol.
- Hemolysis may be avoided by ensuring adequate preload, controlling afterload, ensuring correct device placement, and trending plasma free hemoglobin.
- Device position should be assessed every shift with echo to assess depth and function of the device and ‘less is more’ when it comes to dressing changes.
- Bleeding is critical to recognize, and suction alarms and hypotension can be tip-offs.