Chapters Transcript Video Cardiogenic Shock You know cryogenic shock. These are my disclosures. There are different definitions, right? And most of these definition as you can see are based on systolic blood pressure, less than 90 of mercury non or to keep that blood pressure you need pressure support. Also him a dynamic data where your veg is elevated meaning of filling pressures are elevated. Your cardiac index is less than two. As you can see there are different clinical trials and each added different parameters to the definition of shock. Right? Some are the volume responsive or not. Some studies even lead it more further and their inclusion criteria. Was is there any evidence of end organ damage or how do they look clinically? Is there a clinical sign of hyper perfusion altered mental status? The skin is model. We have seen all these patients and then why it's important to diagnose it early. Because then you see this shock spiral right where you start from left ventricular dysfunction, whether this is chronic or acute from me. And then you start having elevated feeling pressure, hypoxia, hypertension, reduced perfusion. Start having an organ damage and finally resulting in debt. So it's all shocked equal. And it's not you have my cardiogenic shock where you have obstructive disease in the coronaries with rapid deterioration needing support. And then we have chronic heart failure patients which we all see in our heart failure clinic. Those patients are chronically congested and something happens which tips them over. So not all shock is the same. And this really characterizes these patients. So if you can see on the top pink panel the ami shock patients, their elderly, they have diabetes, They need more ways oppressors they present with cardiac arrest. The hospital course, as you can see is mostly characterized by they need temporary mechanical circulatory support. We talk about balloon bombs in paellas and all these devices. They undergo a lot of procedures. They have vascular and access complications which we just learned in the next room in the vascular session. But if you look at the chronic heart failure patients who present with cardiogenic shock, there are different entity, right? They have chronically reduced ejection fraction, they have low cardiac power output, increased pulmonary capillary congestion. And then they have increased pulmonary article stability index. And then what you see is the their hospital courses more geared towards giving them a durable or they are being evaluated for heart transplant. And then these are the patients, everybody is worried about the length of state. Right? So these two entities are different. And as you can see, the one year mortality is quite high in the army cryogenic shock population as well. And that's why we need to know a common language. How do we identify these patients who are at risk and how to talk to each other. This is like a Sky shock classification which is a common transcript. So that one talks about this patient is in cardiogenic shock. What do we mean? So Sky the society of cardiac angiography and intervention has come up with this classification which has been updated this year talks about simple five stages and then each has a modifier where there is a concern for anoxic brain injury. So stage A. Is really at risk of shock. So somebody who is him a dynamically stable who is not in shock but as risk for developing cardiogenic shock. Right? These are patients who have probably somebody with nuanced cardiomyopathy you have seen or anybody who has a large anterior in fact and to further subtype this stage A patients, these are the patients I want you guys to keep an eye on because there might be some of them who may I need help pneumonic who may need help that they need to be referred to advanced heart failure. Who are this patient, they have low blood pressure. They're intolerant to G. D. M. T. You know because when Gmt fails advanced cardiac heart failure work up starts right? So you are trying to evaluate them for transplants, Something like that. These are the patients who have evidence of elevated renal function or they have some elevated hepatic enzymes but they are not in shock. They're at risk. You give them beta blockers or you give them interest under blood pressure drops to 60 systolic, maybe this is a patient who is ejection fraction less than 25% and class three. They are at risk for stage but I do remember them that you may have to refer them for advanced heart failure? Stage B is beginning of shock right now? They're getting a little cold clammy. They're getting tachycardic then now stages classic shock. Your veg pressures are they are also on exam. They're hyper refusing and they may need I know tropes or heading towards mechanical circulatory support are already on one D. Is continuous deterioration. Right? The lactic acid is going up the evidence of end organ perfusion there worsening on current support. You're adding another trope or you're thinking about oh my God from impala I have to now go on ECMO and ease extremists. Their impending doom. They're about to go into refractory shock and complete circulatory collapse. So this really gives an easy burden for somebody to say like you call a physician and say like hey I have a patient in staged the shock. They know that this guy needs to be transferred to get them in the chopper, go to the hub center, put them on a support device before they die. So moving on, what they also proposed is that these three access model, How to evaluate these patients and how to prognosticate. So use your sky stages right for the severity. Use the phenotype. Ng this is a cute, this is acute and chronic. Was the etiology. Is it left ventricular dysfunction. Right ventricular dysfunction from massive pE or RV? In fact this is a patient with bio ventricular dysfunction. Um What else is going on in biochemistry. Right? What are the other risk modifiers like we talked about cardiac arrest, Whether these patients have their advanced age, like somebody 95 you're not going to put them on ECMO. Right? Are the frail nursing home bound patients. So this they also give you a cheat sheet where you can see physical exam, biochemistry and human dynamics to see where each patient belongs and why this is important is each sky stage predict mortality as you can see that in heart failure academy or both heart failure as you move from stage B. C. D. Your mortality goes up and this has been validated by several studies that with increasing style stage your mortality increases and sky stage classification really shock classification really gives you a baseline where you can either follow the recovery pathway meaning if your stage the patient is becoming state see getting better, you know that you're going towards more recovery so then you can initiate GMT as their of while on the other hand, there is a deterioration pathway meaning now you have to really figure out, Okay, do I need to list this patient for transplant or does this guy needs a durable because he's not going to recover or we can't save everybody. Do we need to get to care And why which drives mortalities condition is very common. To see bio ventricular condition more than 50% of the patients and as you know that mortality and morbidity is still driven by venus condition. Whenever patient had an elevated right atrial pressure, which persistent these patients had poor survival. And nowadays it's important to figure out whether this is a hemo dynamic shock, it's just an hemo dynamic issue or it's ahem a metabolic issue. The communist thing we use is lactic levels. You can see here patients who have elevated lactate levels, they have worse survival. And on top of that, if they have poor cardiac power output, which is calculated by your mean arterial pressure, multiplied by cardiac output divided by 4 51 you can see that those who have low cardiac power output and elevated acted. They have very different survival. And you can see that when you add him a metabolic shock, meaning patients who have renal dysfunction, Their cardio renal syndrome, look at their mortality if they have diabetic condition and cardio renal syndrome through the roof. And this is persistently being studied in all the cardiogenic shock subgroups. So, I just wanted to show you this case. This is a 60-year woman who presented to our outside hospital actually, and they were not sure what's going on with her. She had recent answers of shortness of bread shirts and palpitations. She had a sedentary job. And when she presented to them, she had elevated proponents was relatively abnormal. It was really not stem e but as the echo was showing concern for wall motion abnormality. This is also a cute, they just thought that she had stressed in this cardamom took her to the lab and coronaries were normal. These were her physical exam findings. Blood pressure looks normal, slightly tacky Kartik, slightly not really hypoxic but low saturation on exams. Short cold and clammy. And her troponin is high sensitive elevated and chest X ray short conditions. So if you remember the sky shock classification, probably this lady was sky shock be right and maybe going to see because she's cold and clammy. Right? So the physician taking care of her was very astute. He thought something is wrong and quickly referred her to us and you know this is what we saw as you can see really not a normal looking at KGs state changes. Alicia's brady Kartik here, she has psychic arctic on presentation. So something has changed. And you consider all these multi form pvcs on her tele script. The nurse was really concerned about her and as she was in shock. So we decided to re stratify her by doing a right heart cat as you can see she's congested, right atrial pressure is elevated, her wedges elevated. Her cardiac output was only 2.9 liters. She was in a classic stage of shock. Right? So because of this was her baseline echo as you can see this is not normal bio ventricular failure. So how would you manage this patient? What's the next step? We put her on ECMO do we put her on balloon bomb do we just start on iron ore drugs and see so they're different management protocols. And one of the best things to do is to have a multidisciplinary effort. This slide is not really very clear but what a shock team consists of is an international cardiologist. The key component is a heart failure cardiologist, your surgeon and your intensive ist and then you have a slew of team members which you can add according to the place you are at. And for example central we have a great shock program. Once the chocolate goes on everybody gets the same page intensive ist heart failure doctor surgeon bet our chief nursing Manager. They all get on board and even transport they get on board and we decide what's the next best step for this vision that different algorithms to manage cardiogenic shock. This is just one of them to go by the card in cardiac index of this patient. You know I did not show you the lack date. Right? So maybe this lady would be a candidate for either a balloon pump or an impeller catheter. And if there is no improvement then you keep on moving the algorithm to see whether they need bio ventricular support or not. This is just a protocol from Nova where they have nicely tabulated what they do for their cardiogenic shock management from an academy and cardiogenic shock management for their heart failure patient. And this is all over their cat labs and ICUs. And one thing we need to know is just escalating in the tropics support 40 of LIBOR. We are adding two million on this is futile. Look what happens, mortality goes up as you increase the number of pressures and iron ore tropes. So this is not the time to play with fire. You have to be very, very worried about your patient if you're adding drips are escalating grips. So then most other option, other option is a slew of devices. The left sided Impalas right started protect do catheter durable surgically implanted in paellas paellas. Where patient goes on ECMO and needs an impeller on top. There is this new configuration which is known as lava where you unload the left atrium as well as the right atrium and drain the blood and oxygenate it and give it back to the patient. And that's when we need to know the human dynamics. Right swan guns categorization, Right heart catheterization is going to tell you what to do right. If you're mixed witnesses going down, your cardiac output is going down, then you have to escalate the support. If numbers are improving, then you start your winning protocol and back to our patients. She continued to have rapid deterioration. She was started on our troops had more decision was made to put the balloon pump just to get her out of the cath lab, persistent non sustained V. T. We had already october surgical team emergent lee ended up on ECMO and look what happened on ECMO completely increased her after load, more pulmonary congestion. And the arctic route was completely almost about to get clotted off. You see this dense clot in the arctic route. This can go anywhere right, can go to brain, it can go to her coronaries, you can see significant mitral regurgitation here on T. So then multidisciplinary approach of structural heart disease team came in the middle of the night I think DR Mahoney came in and accept Asta me on this lady and look as soon as you unloaded the ventricle the smoke is gone. We were able to excavate her, her pulmonary oedema improved and we knew that she's probably not gonna recover. So she was listed for transplant and got transplanted day five on ECMO. And the biopsy we had done to evaluate this stress cardiomyopathy actually showed the worst kind of myocarditis we called giant cell myocarditis. So you know it's really a team effort and the more you wait on this vision every hour their mortality increases. And that's why now the concept is you know just like we have door to balloon time for stem is there's a concept of door to support time for cardiogenic shock. The longer you wait the worst ticket. Right And look with team effort we are trying to put a dent in this. The survival in mortality is going is the survival is improving. With all the team efforts and organized management pathways of cardiogenic shock And even with the national cardiogenic shock initiative where it's a protocol different management Multidisciplinary approach for shock patients. They have shown that they are able to significantly reduce the mortality in this deadly population. What about CPR patient presenting with CPR? Do you want to treat them in 2022 like this or you want to have this ECMO truck? So Minneapolis has this truck where they go and they can relate they even have a C arm inside this truck and have the ECMO circuits ready to go. This is how I think we should take care of her patients. Would you use this phone today or this one where where it allows you to even uh contact satellite for emergency S. O. S. Crash detection. Okay, so you don't have to call 911 or you go back to what you just saw before you and that's why this is the importance of shock team. You cannot take care of this patient without the team. You cannot take care of these patients alone. Multiple institutes which have shown that an organized team approach improves survival. It really takes a village and I think just like in every other center this is the success story of our center where all of us and so many others which I cannot include in this picture were helpful in saving this patient's life. And to conclude you know cardiogenic shock is really a very morbid condition, very high mortality, But by a team approach, by having protocols, by having shock teams recognizing it early, using sky shock classification to see where this patient stand, really able to reduce mortality due to support, time is really the new mantra. And hopefully, with the team approach and learning the phenotype of short shocks, we will continue to reduce the mortality of this very lethal disease. Thank you. Published December 7, 2022 Created by Related Presenters Amit Badiye, M.D. Sentara Advanced Heart Failure Center View full profile
