CRT Cardiogenic Shock Session S 43 Implementing Cardiogenic

CRT Cardiogenic Shock Session: (S 43) Implementing Cardiogenic Shock Initiatives: Building the Shock Team The Radial Shock Initiative Adhir Shroff, MD, MPH Associate Professor of Medicine University of Illinois – Chicago Jesse Brown VA Medical Center arshroff@uic. edu @ARS_MD 2004 #Radial. First

2 Disclosure Statement of Financial Interest Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below. Consulting Fees/Honoraria/Speakers Bureau: • Terumo • Cordis • Abiomed • Medtronic Equity Interests: None Royalty Income/Intellectual Property Rights : None Salary/Salary Support/Employee: None Adhir Shroff, MD, MPH Associate Professor of Medicine

3 Agenda • Review the clinically available data on TR-PPI for shock • Review concerns about D 2 B, hemodynamic support, anticoagulation • Tips and tricks Adhir Shroff, MD, MPH Associate Professor of Medicine

Transradial vs Transfemoral for Shock • French study, 101 consecutive patients with cardiogenic shock • Access site, choice of medications, HD support use at operator discretion • 73% TR, 27% TF • No difference in PCI success rate • No difference in use of HD support Arch Cardiovasc Dis. 2015 Nov; 108(11): 563 -75 Adhir Shroff, MD, MPH Associate Professor of Medicine

p<0. 05 P=0. 06 p<0. 05 Transradial vs Transfemoral for Shock • French study, 101 consecutive patients with cardiogenic shock • Access site, choice of medications, HD support use at operator discretion • 73% TR, 27% TF • No difference in PCI success rate • No difference in use of HD support • TR: Lower death, access site complication, and death/MI • TR patients: younger, less cardiac arrest, less complex, more male Arch Cardiovasc Dis. 2015 Nov; 108(11): 563 -75 Adhir Shroff, MD, MPH Associate Professor of Medicine

6 PPCI for STEMI: RIFLE & RIVAL RIFLE-STEACS RIVAL-STEMI Radial Femoral NACE 13. 6% 21% MACE 7. 2% 11. 4% Death 5. 2% 9. 2% Non-CABG bleeding 7. 8% 12. 2% J Am Coll Cardiol 2012; 60: 2481– 9 J Am Coll Cardiol 2012; 60: 2490– 9 Adhir Shroff, MD, MPH Associate Professor of Medicine

7 PPCI for STEMI: RIFLE & RIVAL RIFLE-STEACS RIVAL-STEMI Radial Femoral 3. 14% 5. 19% 11. 4% Death/MI/stroke /bld 5. 2% 9. 2% Death/MI/stroke 2. 72% 4. 59% 7. 8% 12. 2% Death 1. 26% 3. 19% Major bld (ACUITY) 1. 99% 4. 1% Radial Femoral NACE 13. 6% 21% MACE 7. 2% Death Non-CABG bleeding J Am Coll Cardiol 2012; 60: 2481– 9 J Am Coll Cardiol 2012; 60: 2490– 9 Adhir Shroff, MD, MPH Associate Professor of Medicine

PPCI for STEMI: MATRIX Outcomes Radial Femoral NACE 13. 6% 21% MACE 7. 5% 8. 5% All-cause Death 2. 4% 2. 7% BARC 3 or 5 bleeding 1. 9% 3. 0% Any bleeding 9. 4% 16. 3%* FA, RA European Heart Journal (2017) 38, 1069– 1080 Adhir Shroff, MD, MPH Associate Professor of Medicine

9 Common Concerns for TR-STEMI Increased D 2 B Times Hemodynamic Support • In RIFLE-STEACS, no difference between TF and TR • Most trials have excluded patients in shock • Use of such systems can be safely introduced via the TF approach • Case series of IABP and larger PCAD system have been reported J Am Coll Cardiol 2012; xx: xxx *Bell, et al. CCI 2011 Adhir Shroff, MD, MPH Associate Professor of Medicine

10 TR-STEMI and Anticoagulation US Operators using less Bivalirudin Non-Access Site Bleeding • Has been reported to be more common than access site bleeding (3. 2 vs 2. 1)* O-US US Catheter Cardiovasc Interv. 2018; 1– 12. *J Am Coll Cardiol Intv 2011; 4: 191– 7 Adhir Shroff, MD, MPH Associate Professor of Medicine

Primary PCI: Indications and Procedural Aspects Adhir Shroff, MD, MPH Associate Professor of Medicine

Primary PCI: Indications and Procedural Aspects Adhir Shroff, MD, MPH Associate Professor of Medicine

US Guidelines • Recommend TRA for primary PCI to reduce vascular complications and bleeding Catheter Cardiovasc Interv. 2020; 95: 245– 252. • TRA should be default strategy for ACS patients Circ Cardiovasc Interv. 2018 Sep; 11(9): e 000035. Adhir Shroff, MD, MPH Associate Professor of Medicine

Adhir Shroff, MD, MPH Associate Professor of Medicine

15 Tips and Tricks • • • Not for beginners to the radial approach Need experienced TR-operators and TR-staff Set a time limit for access and engagement Would recommend routine prep of groin Use of a multi-fenestrated drape for ALL cases will decrease prep time Adhir Shroff, MD, MPH Associate Professor of Medicine

16 Questions? ? ? Thank you. Adhir Shroff, MD, MPH Associate Professor of Medicine