Case Review, Complete Revascularization, AMI Cardiogenic Shock
Cardiogenic Shock Heart Recovery Case Study with Impella® Support Prior to Complete Revascularization
James Park, MD, FACC, presents his first NCSI study enrollee—a patient with cardiogenic shock with prolonged resuscitation and multiple shocks—in whom he initiated support with the Impella heart pump prior to revascularization. In addition to presenting this good heart recovery story, Dr. Park shares how his center is striving to improve the quality of care and outcomes for patients with cardiogenic shock. Dr. Park is the director of the cardiac catheterization laboratory at Texas Health Presbyterian, in Dallas.
The patient, a 41-year-old male with no medical or cardiac history, experienced cardiac arrest at home. He received more than a dozen shocks for ventricular fibrillation/ventricular tachycardia prior to arrival at the hospital and again in the ED before he was transported by ground to Dr. Park’s facility.
“This was a case where I really felt that support would be essential before I even started any angiography or reperfusion,” Dr. Park tells interviewer George Vetrovec, MD. “So, I started access on the left side and placed an Impella first.” Upon initial placement of Impella, Dr. Park noted no phasic waveforms on the placement signal, indicative of significant myocardial shock, but because the patient had a mean pressure above 90, Dr. Park felt he could proceed without CPR.
Dr. Park explains that he felt the patient required complete revascularization. With Impella support, he was able to fix the culprit, the circumflex artery, as well as the right coronary artery and LAD and complete the intervention without CPR.
“I’m not sure if this patient would have made it if we did not support prior to me doing the coronary angiogram. I feel that given that the placement signal was completely flat, if we even delayed by a few minutes, I think we would have had to start CPR on him, which would make the whole situation a lot worse.”
In the ICU post-revascularization, the patient’s cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi) indicated that the patient was still in shock (CPO=0.759 and PAPi=0.68). Ejection fraction (EF) was about 15% and initial echocardiogram showed profound hypokinesis consistent with STEMI. However, over the next 48 hours the patient steadily improved and LV function and movement improved. On outpatient follow-up, the patient had an ejection fraction of about 40%.
Dr. Park describes his center as “a very robust, non-academic center” that is a receiving center for a lot of complex cases. He explains that his center has had a significant growth in their use of Impella, particularly in cases of cardiogenic shock related to acute myocardial infarction.
“We’ve had a significant cultural change in our facility, and I’m trying to propagate that throughout the system,” Dr. Park explains. “I feel that LV support is very important prior to any revascularization in situations like this.” He emphasizes that many interventionalists still feel that they need to do reperfusion or coronary revascularization before any LV support and that this clinical cultural change requires interventionalists to reconsider the role of LV support and when it is initiated.
He also describes how his center has had to wrestle with other important questions such as: How do we do escalation earlier rather than later? How are we using the hemodynamics—the numbers like CPO and PAPi—to make those decisions? And how do we incorporate the whole team, including the surgeons, in terms of the escalation and devices?