Team Approach to the Management of Shock: Tailoring Therapy for AMI Cardiogenic Shock (Part 3)

Best Practices Learned From INOVA-SHOCK Experience

Benham Tehrani, MD, FSCAI, discusses best practices learned from the INOVA-SHOCK experience. Dr. Tehrani is an interventional cardiologist and medical director of the cardiac catheterization laboratories at the Inova Heart & Vascular Institute in Falls Church, Virginia.

Dr. Tehrani discusses how a comprehensive hemodynamic profiling of patients in cardiogenic shock may help to identify these patients earlier and provide early and tailored approaches to therapies. Just as all shock is not the same, he explains, not all MCS devices are the same and it is important to know which device is most appropriate for which patient. Regularly assessing patients with invasive hemodynamic monitoring is critically important for tailoring therapies to patients.

In addition to understanding treatment objectives, Dr. Tehrani emphasizes the importance of the multidisciplinary, team-based approach to managing cardiogenic shock and the importance of coordinating team members and following protocols. He explains the processes and best practices implemented at Inova and the positive results achieved.

Treatment Advances in Cardiogenic Shock

Bartley Griffith, MD, discusses how the Impella® heart pump, extracorporeal membrane oxygenation (ECMO), and the combination of the two are being utilized to improve outcomes in patients with cardiogenic shock. He describes a recent surge in the use of ECMO, an increasing use of Impella since its introduction, and a rising “tsunami of interest” in combining ECMO and Impella to avoid left ventricular distention seen with ECMO and “enable ECMO to do what ECMO does best.”

Dr. Griffith highlights the cardioprotective mechanisms of LV unloading: decreasing myocardial oxygen demand, increasing myocardial oxygen supply, and creating a “healthier environment: for cardiac improvement and recovery.” He also notes that as a personal proponent of ECpella—the combination of ECMO and Impella—he believes that in select patients ECpella is necessary for a good outcome, and once clinicians become more comfortable with these devices, the “secret sauce of care” will bend toward favoring outcomes in ECpella. He goes on to present data from Russo et al., (JACC 73(6), 2019), Pappalardo et al., (Eur J Heart Fail, 2017), Patel et al, (ASAIO J, 2018) describing improved survival with Impella unloading in cardiogenic shock; and Cheng et al, (J Invasive Cardiol, 2015) describing the lack of survival benefit with intra-aortic balloon pump (IABP) unloading.

He concludes his presentation with case studies. In the first case, Impella 5.0® was added to VA ECMO and Dr. Griffith notes that after this experience, he will be more likely to evaluate and move to Impella sooner in such patients. He then describes the first patient to be treated with Abiomed Breethe OXY-1 System™, which he notes “might be an important addition to the Impella armamentarium.”

Identifying Right Ventricular Failure

Babar Basir, DO, FACC, FSCAI, director of the acute MCS program at Henry Ford Hospital in Detroit, describes the basic pathophysiology of right ventricular failure (RVF), common invasive measures to diagnose RVF, and use of Impella RP® in the management of RVF.

Dr. Basir explains that RVF is common, complicating about 40% of AMIs and is also associated with other cardiovascular conditions including long-standing heart failure. He also explains that the shock initiative provides some insight into the effects of early left ventricular unloading on the right ventricle. Any increases in pulmonary afterload have significant right ventricular consequences, he explains, emphasizing “the number one reason for having right ventricular dysfunction in patients with heart failure is secondary to left ventricular dysfunction, because of this component of afterload.”

Dr. Basir describes how hemodynamic measures as well as diastolic suction alarms on the Impella console can be used to identify patients with RV dysfunction and inform cardiogenic shock clinical decision making. The majority of patients, he explains, present with some degree of biventricular dysfunction; however, after 24 hours of LV unloading the majority of these patients improve. While appropriately selected patients require right ventricular support with devices such as Impella RP®, RV dysfunction can often be treated with early LV support because patients have predominantly left ventricular failure.

“The shock initiative has given us a really useful algorithm to be able to treat these patients who present in cardiogenic shock. And I think one of the keys is to be able to follow the hemodynamics of these patients. So if you’re able to achieve a CPO greater than 0.6 watts, if you have a PAPi greater than 1, with an RA pressure less than 15, within 24 hours these patients do tremendously well and their overall survival is over 80%.”