Chapters Transcript Video Hemodynamics Matters So, uh I'm gonna differ a little bit from the, the objectives here that I um uh set out in, in some ways, I'm gonna start off with a case. Um, that, uh I thought was particularly interesting and um I want you to, um, I'm not going to call on you specifically, but I'd like you to sort of think through and um, and be suspicious. Um Not that I'm trying to trick you or anything, but um I think it'll be helpful in, in uh in the end and uh kind of a good learning case. But I want to talk um uh overall about cardiogenic shock, a lot of ways this talk could go. I think, you know, um uh a lot of um hemodynamic principles in the Cath lab um that are uh extremely important. But what I'll do is I'll talk to you about this case and then I'll build off of uh cardiogenic shock. So, uh we had a case, um uh 72 year old female presents to the emergency department. She's in significant res respiratory distress. Um And uh uh em, ems brings her in Ed CS her and uh this is the EKG that they get initially, um I can't say I was uh uh specifically um there at this time, but uh the thought was that uh potentially uh the patient had some um some T waves in her V two and V three, maybe V four that were hyper acute. Um So, uh potentially in a conclusion of I um also uh the patient was um clutching at her chest, nodding, yes, to pain. Um um she uh initially tt a cartage of about 100 and 10 beats per minute. Her blood pressure was in the one fifties or so, um over sixties to seventies. So a little on the hypertensive side, uh initial SATS on room air were approximately 68%. Um uh put on a bipap to her. Uh That's when cardiology had the uh the initial um and initially saw her sats were improved for about 91%. Uh at that point, you know, she was um in and still in quite a bit of distress nodding. Uh Yes, to chest discomfort, obviously feeling extremely short of breath and clutching at her chest uh vitals at the time, um uh stayed pretty uh stable there. And then, um looking at that EKG plus the patient patients presentation, uh we decided to take her to the Cath Lab, by the way, she, you know, uh we were able to get some uh extra information, you know, hadn't hit her head, didn't have any sort of bleeding issues uh just from a quick um interview of the patient uh with the limitation, of course that she was on BIPAP. Um So, uh we decided to take her urgently to the Cath Lab for that reason. Uh as we were transferring her to the Cath lab table, this happened um of course, we can never find strips. So I stole this one, but that essentially happened with her. Um uh I think thank you, life in the fast lane, I believe. But um so we placed her on the cath lab table and as we're uh getting uh geared up to, to start this case, uh this happened. Um So we finished, transfer her over, luckily she has the um uh the pads on and she uh receives one shock. Um One shock. Um We initially were going to start CPR sort of as we were starting CPR, she pushed us off. So we got started with the case. Uh hemp dynamics were um were ok at this at that time, you know, she was still having quite a bit of um respiratory distress but was doing ok to be lying flat. I would, I should say um her stats were in the low nineties and then her blood pressure um at the time was, you know, about 100 and 10/1 20 systolic or so. Um So, um hanging in there, she was still tachycardic and um we uh decided to go uh grow an access for her. So uh we accessed her uh right from her artery. And uh when we first, we were, our plan was to shoot the right coronary artery. Before we did that, we crossed the valve and um obtained an LVEDP which um it's hard to see the, the lines there. Um But um we, we uh initially called it, you know, maybe 18 or 20. Um and then uh pull back across the valley. I don't think they captured that. Uh And then we engaged the RCARC A was a large dominant vessel with uh with no significant stenosis. So then we turned our attention to the left ma uh left system just hit it. So as you can see here, um I'll keep, oops, let me go back. I guess I'll just play one time. Well, um So she had a, a critical L ad stenosis, uh you know, 80% or so. So the, the plan was to, to intervene on that, that thinking that was the corporate lesion and, and probably fits with those hyper acute T waves and cordial leads. So, um I started uh the case, uh we switched to a guide uh catheter. We uh successfully wired her uh L ad um uh with one wire and uh as we advanced the balloon to the left main, you know, didn't do any angioplasty, just sort of just got it inside of the vessel. Uh She uh had an, another episode of B FB. Um At that time, it took a little longer to get her back. So CPR for about three minutes um uh loaded am ofe the whole um uh the whole nine yards there got uh two defib that time and finally achieved Ros um didn't put that here, but um obviously she was uh intubated uh for airway protection. Um At the time we had had a Nora hanging, we started uh Nora and um, you know, we thought that maybe she would, she had mildly improved. Her, um her SATS were obviously much better um uh after being intubated and then her blood pressure was uh low after that, you know, in the essentially nineties, um systolic, I believe and map was hanging around 6065 though. Um So it started a uh Nrab uh uh uptight trade, it pretty quickly to about 15 or 20 uh uh proceeded with the case. So, um uh we uh Ives first and then um predilated with a 25, a 15 compliant balloon. Uh immediately after that, uh predilation, the patient had another VFIB arrest. So, um uh shocked one time that in that instance and got an immediate risk um at that point, the blood pressure um was, was much lower map was about 5055. So thinking that she was uh headed off the curve into cardiogenic shock. Now, uh some of our doing and some of the um the uh occlusions uh doing, we started debut Iine uh subsequently collapsed uh co completely. So, um uh we ended up calling uh an Eco alert. Um We were rapidly up titrated her norepinephrine. Um So, uh she was sort of hanging on in terms of uh maps. They were uh roughly in the forties or so, um was uh not getting good oxygenation. Um uh placed an uh bloom pump uh through her left femoral artery and um uh like I said, called a shock alert for possible ECMO. So here, um I hope this is long enough. So, during the E CMO um in our institution, uh we have so I guess I can outplay that one. Thank you. Uh So, uh I don't know if you can uh appreciate this here. Uh But uh this uh explains our, our conundrum and, and why we're sort of vexed of uh the ongoing collapse. Um I, I think so basically, uh at in the process of the uh co alert uh had a, a bedside echo there and uh this is what we saw. So you see, um you can see the, the septum there is, is pretty thick, there's also some mid and apical cavity obliteration and then I don't know if you can really appreciate. It may not have been the best um one to show but there's some coral sam. So, uh when she uh with uh each systolic beat, her mitral valve is obstructing her LV, outflow tract So, um essentially, um we thought we were uh being uh kind of uh dealing with uh LVF tract obstruction physiology. And in that case, we stopped the dobutamine, uh you want to stop uh any inotropes that will make that worse and, and likely precipitated her collapse. Uh Phenylephrine was initiated uh map improved, nor B was weaned down and then finished the case successfully. And uh I think um I also stole this uh as well. Um But II I ran through purposefully uh you know, pull back, we couldn't record that and sometimes that happens. I think that just talks to the importance um of, of, you know, making sure you have a good understanding of uh what's happening um with the patient. And uh the importance of LVEDP, I think is very important too. Can I go back um a few slides to the beginning. How do I do that uh to my first tracing? OK. Thank you. So, here um I also um was um was deceiving you a little bit. So I think I, I was just going to use this to, to talk about an uh another component before I go along. Um I think it's really important to, to make sure we're getting the right uh measurements and hemodynamics definitely matter. Um Here, I it's hard to tell, I wish I would have grabbed a better example for you. But um you know, if we're roughly saying that the um the second beat there. If, um, if the, uh, if the beat in the middle there during diastole, that's sort of the, the small hump that you see the raise and pressure and then it, uh, dips down again. Um, if you quickly are, are going through, um, and you have a PC I, someone's in shock, uh, you're trying to get things done. Um, you might call that the LVEP but that's not, it's, um, actually, uh what you should do is you should look after the P wave and it should be the LV, uh A wave if you want to call it, that, that should be your true led. P So in this case, it's an extremely high LVEDP. Um You can also tell, um you know, uh I won't go into that right now, but using your right atrial pressure and, and overlaying them, you can tell if someone's even incom versus decompensated uh um heart failure. And, and this just goes to show, you know, uh with this uh tracing. Um if you see something like this, it might give you um you know, an indication of impeller or something like this to offload the patient before you uh go uh ballooning and trying to fix that um that vessel, just another learning point. And that was um uh h come across the valve and, and this is just um uh an illustration of what the, what was happening for her. So with sly uh that um mitral valve leaflet is giving her a very significant outflow tract obstruction in addition to her mid cavitary out uh mid cavitary obstruction. So, um you know, just uh I was just gonna run through uh a little bit and talk about cardiogenic shock um uh in general. So, uh essentially, uh it's uh the result of a low cardiac output um and the absence of hypothalamic leading to um uh several changes. So, um obviously, hemodynamic changes, biochemical changes uh due to poor tissue perfusion. And um it could be several things and those things are very important to us. And the Cath lab in terms of how we're going to treat the patient, what mechanical support, we choose uh what the underlying disorder is in general. Um And um we, we kind of break that into myocardial dysfunction, LVRV or biventricular failure, uh any sort of valvular disorder, which um that is several talks on its own. So I won't go into that into great detail, uh arrhythmogenic shock and then um uh pericardial um ideologies as well. Um uh Tampa not, is it can be sort of an obstructive shock as well, but uh I also won't go and dive into that too much. Um Really for us. Um You know, we want to cover uh my cardial uh causes of shock. And so, including uh acute mis uh in this case, uh felt like that's what we, we were dealing with an acute M I and then, you know, leading to cardiogenic shock, um acute decompensated heart failure, of course, is probably the one we may run into the most. Um Here it was a dynamic LV, outflow tract tract obstruction that we made worse and uh uh precipitated that decline. Um Also, um something that we see not uncommonly is um after cardiac arrest, the heart stunned can also lead to, to cardiogenic shock. And then something they don't see quite as often, but um may get a consult uh to go to the trauma unit, my cardio contusion, uh especially with the RV free wall, something we um uh see fairly often as well. Um I won't go into uh to this uh too much but um really wanted to um uh just get into um uh some of the, the criteria that we use. Um And uh just thinking, what are we going to use in terms of uh uh support, how are we going to make this classification? And um I, I think I just add a few uh parameters here. So we have on the left this um shock criteria. Um And then um uh for a clinical basis on the right side is um uh hemodynamic criteria. Uh you know, using a combination of the two and using a combination of the cardiac index wedge pressure, um blood pressures uh in general, um CV, plvedp uh with the patient presentation in addition to lactate and some other things like this, we're able to, to better define um what's actually happening here. And I think this, you know, the thing I would take away also from this, um that I've sort of uh learned is uh in my early career is that, you know, someone like that who's coming in, if you can do a right heart catheterization to um to better define things. Um I mean, obviously there are situations where you have to do what you have to do. But um I think that is extremely helpful in this situation to risk stratify the patient and give them uh uh better support uh in general. Published November 14, 2024 Created by Related Presenters Brian K. Mitchell, MD Cardiology, Internal Medicine View full profile
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