Key elements of a cardiogenic shock team Associate Professor of Medicine Medical Director, Cardiac Intensive Care Unit Director, Interventional Cardiology Fellowship Program Co-Director, Cardiac Catheterization Laboratory University of Chicago Medicine | Chicago, IL Sandeep Nathan, MD, MSc, FACC, FSCAI Getinge symposium | SCAI 2019 | Las Vegas
27
Embed
Key elements of a cardiogenic shock team · 2019-05-21 · Right ventricular failure (RVF) / RV shock • Right ventricular failure (RVF) results from any structural or functional
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Key elements of a cardiogenic shock team
Associate Professor of Medicine
Medical Director, Cardiac Intensive Care Unit
Director, Interventional Cardiology Fellowship Program
Co-Director, Cardiac Catheterization Laboratory
University of Chicago Medicine | Chicago, IL
Sandeep Nathan, MD, MSc, FACC, FSCAI
Getinge symposium | SCAI 2019 | Las Vegas
Disclosures
Affiliation/Financial Relationship Company
• Grant / Research Support None relevant
• Consulting / Advisory Panel / Honoraria Abiomed
Cardiovascular Systems, Inc
Getinge
Terumo Interventional Systems
• Major Stock Shareholder/Equity None
• Royalty Income None
• Ownership / Founder None
• Intellectual Property Rights None
• Other Financial Benefit None
ML-0801 Rev A/MCV00091529 REV A2
Therapeutic targets in the
management of cardiogenic shock
ML-0801 Rev A/MCV00091529 REV A3
Progression of cardiogenic shock from a
hemodynamic problem to a cardiometabolic syndrome
Reyentovich, A., et al. Nature Reviews Cardiology 2016.
Myocardial ischemia
Hemodynamic
instability
Volume overload &
systemic hypoperfusion
Coronary perfusion
End-organ
dysfunction
Clinical stability
Death
Culprit PCI
Vasoactives → LV/RV
unloading w/pMCS
Escalation of pMCS /
devices in combo?
Complete revasc?
Renal & hepatic unloading, renal replacement Rx
ECG ’s, sxs, cardiac
biomarkers
MAP,
LV-ESP & EDP
Aortic pulse
pressure
Pulmonary
edema, BNP,
Neuro ’s,
lactate
ECG ’s,
biomarkers,
ventricular
arrhythmias
Creatinine,
LFTs, lactate,
coagulopathy
ML-0801 Rev A/MCV00091529 REV A4
Right ventricular failure (RVF) / RV shock
• Right ventricular failure (RVF) results from any structural or functional
process(es) that decrease the RV’s ability to pump blood into the
pulmonary circulation
• RVF and/or RV shock are rarely seen in isolation in the critically ill patient
outside of pure RV infarction
• RVF is increasingly being recognized as a key contributing factor to critical
illness across a variety of medical and cardiac illnesses
• The addition of RVF to critical illness portends poorer outcomes although the
magnitude of this negative impact remains poorly characterized
• The pathophysiology of RVF, as with LVF, is complex and varied but
remains less studied than LV failure
ML-0801 Rev A/MCV00091529 REV A5
Is it really as distinct as LV- vs. RV-shock?
• Hemodynamically defined RV dysfunction is common in AMI-CS and is largely undetected in
the absence of invasive hemodynamic assessment
Esposito M., and Kapur, N. F1000Research. 2017.
Lala A, et al. J Cardiac Fail 2018;24:148–156.
ML-0801 Rev A/MCV00091529 REV A6
Goals of care in cardiogenic shock
Early recognition & triage
Standardized diagnostic criteria Defined classes & stages
Multimodality assessment of cardiac and end-organ function
Early & continuous multidisciplinary input
Clear delineation of the initial careplan & escalation strategy
Early revascularization (when
appropriate)
Appropriate selection &
early use of MCS
Rapid escalation (or de-escalation) of care, as required
Involvement of consultants & ancillary service providers