Cardiogenic Shock Case Presentation Nauman Khalid Sunday March

Cardiogenic Shock: Case Presentation Nauman Khalid Sunday, March 03, 2019

Nauman Khalid, MD I have no relevant financial relationships

Case description • 56/F, NICM (EF 20 -25%), CKD, DM • 11/6/18 – 11/14/18: – Admitted OSH for HF. – Tx with diuretics, inotropes. Weaned, d/c home. Cr 1. 5 • 11/28/18 - 12/5/18: – Readmitted with ADHF (stage D, class IV symptoms) and AKI on CKD (Cr 2. 4). – Started on Dobutamine, titrated to 5 mcg/kg/min

RHC 12/4/2019 Hemodynamic Parameters RA (mm. Hg) 25 RV (mm. Hg) 62/24 PA (mm. Hg) 64/36 (mean = 45) PCWP 36 PA sat 39% Cardiac output by thermodilution 2. 1 L/min Cardiac index 1. 3 Pulmonary artery pulsatility index (PAPi) 0. 8 RA: PCWP 0. 7

Hospital course • Started Milrinone 0. 25 mcg/kg/min • Transferred to WHC (12/5) for advanced therapies – refractory cardiogenic shock (on 2 inotropes) and – multi-organ failure (↑Tbili, Cr, Lactate) • 12/6/18 → Impella CP placed (left axillary) • 12/6/18 – 12/10/18: – Dobutamine weaned. Impella and Milrinone continued. – Developed hemolysis. Tachycardia (AF/AFL). No ablation – Given no improvement in clinical status decision to escalate care

Hospital course • 12/11: Impella explant, HVAD (Heart. Ware), RV Centrimag implant • 12/12/18 – 12/19/18: – Aggressive diuresis. Pressors weaned. IV Epoprostenol inititated. – Hemodynamic status improved. RV flows progressively weaned down. HVAD flows improved. • 12/20: Centrimag weaned and explanted. Post-op course notable for – Hypotension requiring inotrope/pressor. – HVAD flows low, minimal pulsatility. Tachycardia – Oliguria/Anuria. Started on for SCUF for volume management

Hospital course • Required escalating doses of inotropes / vasopressors – Dobutamine 10 mcg/kg/min, Epinephrine 3 mcg/kg/min, Epoprostenol 50 ng/kg/min and Vasopressin 0. 04 units/min • Brought to the catheterization lab 12/21 for hemodynamic assessment

Next step?

Baseline Hemodynamic Parameters RA (mm. Hg) 18 RV (mm. Hg) 36/15 PA (mm. Hg) 30/18 (mean 20) PCWP 15 PA sat 55% RA sat 69% Cardiac output (thermodilution) 2. 43 L/min Pulmonary artery pulsatility index (PAPi) 0. 67 RA: PCWP 1. 2

Post Impella RP Hemodynamic Parameters RA (mm. Hg) 10 PA (mm. Hg) 40/30 (mean 36) PA sat 58% Pulmonary artery pulsatility index (PAPi) 1

Hospital course • Impella RP / HVAD support continued. • 12/31 – Tracheostomy; failure to wean from mech vent • 1/4 – 1/5 Leukocytosis WBC ↑ 38000. Pancultured. – No source identified. Impella RP suspected as a source → Explanted 1/7 • Continued to require inotropic and vasopressor support • 1/8 – DNR • Showed some improvement but waxing and waning course. Developed sepsis, multi-organ failure. • Made comfort care by family and died on 2/9

Right ventricular assist devices • Surgical RVADs: – Centri. Mag pump or RA-to-PA cannulation with either a thoracotomy or an open sternotomy. • Percutaneous RVADs: Kapur NK et al. Circulation. 2017; 136: 314 -326. – Extracorporeal centrifugal flow devices such as Tandem-Heart, venoarterial extracorporeal membrane oxygenation [VA-ECMO] or axial flow devices, e. g. , Impella RP.

Impella RP • Percutaneous RVAD approved by FDA in 2017 for temporary RV support • 22 F microaxial pump mounted onto an 11 F catheter • Flow ~ 4. 0 liters/minute • Delivered through 23 F peel-away sheath over a 0. 025 -inch guide-wire • Inflow positioned in IVC, & outflow in PA just proximal to PA bifurcation Impella RP

FDA letter • 30 -day survival: – 73. 3% premarket clinical studies – 17. 4% post-approval study • Root cause for this increased mortality remains unknown and may include: – Patient selection, lack of adjustment of confounding variables or the different pre-implant characteristics of the patients in the premarket and the post-approval studies. FDA letter. Feb 4, 2019. https: //www. fda. gov/Medical. Devices/Safety/Lettersto. Health. Care. Providers/ucm 630610. htm

Patient received a surgical LVAD within 48 hrs and has any of the following? Patient not a candidate if meets any one criteria

Thank you