Well, good morning, everybody. How are you? Thanks for coming this morning to our early morning session, and I guess we're honored to start this symposium today and really kick off an exciting meeting. This is the first in-person since COVID, I believe, so this is a great opportunity to network, and we're really excited to be here. So chose an interesting title this year because we normally don't think about the I in team, but there is a lot of I's in team, and that I idea is that we are changing the face of medicine and bringing it to the 21st century in terms of our understanding of how we impact the care of our patients, especially when exploring cardiogenic shock, exploring the ICU, and what our discussion today is going to be centering about is Impella technology to meet the needs of your patients. So read the slides real quick. Got it? And especially the bottom part because there's a quiz at the end, so I hope you got it all. So the idea for being here today really is coming from our awareness about cardiogenic shock and the National Cardiogenic Shock Initiative, so we can thank our colleagues for recognizing the importance of standardizing care for our patients and bringing forward what we need to do to work as a team in this environment. And all of you know this, and I just like to highlight the importance of the fact that our patients are changing in the ICU, and we have to be ready to meet those challenges. And interestingly enough, our colleagues reported from the Critical Care Network database that over 33% of patients presenting into the ICU are a combination of heart failure and cardiogenic shock, and that's a huge change from what we were used to, and certainly our skills and our needs to meet these patients have to adjust and adapt. We also know that mechanical support has risen in the new transplant designation system, and we have to recognize that allocation system is driving our need to understand this type of technology, and we're going to continue to see this rise as we recognize that we can support patients with mechanical devices and get them to transplant in one direction as opposed to using a more durable support technology. And the type of devices we're using is changing as well. Mechanical support shows a clear pattern of changes in device selection. The use of balloon pumps have fallen as we've seen a rise in percutaneous devices and VAECMO, and we're going to continue to see this change, and so bringing your skill set to that will help only to make you better clinicians. We do have a lot of work to do. As reported here, you can see that 10% of the patients entering into the ICU have mechanical circulatory support needs, but 30% have a mortality rate associated with that mechanical circulatory support, so we need to really drive our ability to take care of these patients and raise our skill set. With that is the introduction of the term acute heart failure. We've heard many terms over the years, acute decompensated heart failure, acute on chronic heart failure, but what we've always been treating is this concept of acute heart failure, and whether the patient has cardiogenic shock or the patient does not have cardiogenic shock is the question, and how do we define cardiogenic shock? It's with the evidence and presence of hypoperfusion. It's that hypoperfusion or inability to deliver blood to the body that's going to define what we do in terms of cardiogenic shock and preventing the spiral. Regardless of the ideology of cause of cardiogenic shock, it's important to recognize that if we don't stop the spiral, we're going to end up in the same place, and that's in a gurney, and hopefully we can work as a team ahead of that to stop that progression. And how do we stop that progression? It's by having meetings and discussions like we're going to have today. So we have two very talented speakers which I'll introduce in a moment, but the goal of this discussion is to recognize cardiogenic shock, it's to recognize how to impact cardiogenic shock, and it's the ability to impact how we address the state of hyperperfusion. So now I'd like to take the time to introduce our esteemed speakers this morning who will be sharing their wealth of knowledge and expertise in the field of critical care. Dr. Gutierrez is a board-certified critical care intensivist and the medical director of the CVICU and CCU at Baptist Medical Center in Jacksonville, Florida. He completed his undergraduate study in biologic science at the Florida International University and attained his medical degree at the Universidad Latina de Costa Rica. How did I do? Good. Some of you may recognize him from his Instagram handle, at eddyjoemd, where he educates about concepts in critical care medicine, or from his podcast, The Saving Lives Podcast. Yeah, that was very important. That was really important. I messed that up. Yeah, sorry. He is a CME faculty presenter and former clinical instructor at Mercer University School of Medicine. Our first speaker today actually is Dr. Dan Herr, is the director of critical care at Hilton Head Hospital and the vice president of ECMO Virtual Advisors. He recently left the University of Maryland as the chief of critical care services and director of the cardiac surgery unit and ECMO director. Dr. Herr received his master's of science in pharmacology from Thomas Jefferson University and a medical degree from St. George's University School of Medicine in Grenada. He is a board-certified in internal medicine, critical care, and neurocritical care. And as a fellow of the American College of Critical Care Medicine, he has published his research extensively and has shared his expertise as a chapter author for several reference guides, including the SSCM Guidelines for Sedation in Critically Ill Patients and the ELSO Red Book. So Dr. Herr will be kicking us off today as he discusses the importance of identifying the patient in the cardiogenic shock spiral. Thanks Linda. All right, I've got to get my clicker. Right there. All right, so we need my presentation. There we go. And we need it on screen. There you go. So, I'm an old guy and I don't want to insult you when I talk about cardiogenic shock because I hope some of you at least know about it, know it exists. But I am going to do my objectives and that's just not to insult your intelligence, I hope. To make sure that you know how to recognize cardiogenic shock, to convince you, this is the tough part, what a pulmonary artery catheter is and why you should use it. Once you know what kind of cardiogenic shock is what we have, how to proceed with that, and then the management of cardiogenic shock. And I think Eddie's going to probably do more of that than I am. So, here we go. I want to just one quick word about cardiac arrest. If you don't have these three things, you're probably not going to do a good job at cardiac arrest. Because in this day and age, you have to figure out what kind of shock you have. So, you've got to have a thumper. I guarantee you, if you don't have what I call a thumper, whatever the name of it they have, they have like three different types now. But you have to have one of these. You've got to spell people off. You've got to have time to make your decisions about where your next step is. And this is a device that really gives it. Then you also probably should have some type of ECPR system. If you don't, you should probably find a place, the hub and spoke type system to put your patient if you're not getting better. Because once you put them on ECMO, you have the chance to really take the patient to cath lab, do anything you want. The cardiac system is completely supported. After that, if you've made your decisions and you've got your system, now you have the mechanical support. You have things like Impella, Tandem Heart and other devices. I just want you to know, in my world, it was kind of funny. I worked at a kind of a smaller hospital at first when I first started my career. And we saw lots of MIs and stuff. And then we got bigger. And pretty soon, they started disappearing. You've got to realize that most of these events occur at small hospitals, not your academic centers. So how many of you are from small hospitals? Yeah. And how many of you are from academic hospitals? So it's a split. So some people get the patients and they don't know what to do with them or they got stuck with them. And then the other half is, oh, I want to get them to an academic center. Oh, they don't have any room. So I think, you know, I came, I went from a huge academic center in Maryland and ended up at Hilton Head Island. And I had to be reminded every day, this is an island, Dr. Hur. But we did Impella. We did Impella. So we did know how to take it. And we had a cardiogenic shock team in this small 80-bed hospital. We had a cardiogenic shock team because we had people having heart attacks. Hilton Head Island is what, 80 and above? I think age group? I'm not sure. So have we done well? We haven't done well. I think you all know the data. We have not done well in resuscitation or cardiogenic shock. And we're still trying to get better. And if you look at some of the numbers, it's kind of interesting. We have done well on one thing, and that's bleeding and transfusion. And thank God we've done that, right? At least we've done that right. And I think that's also mainly because of the critical care group. They're the people, not the surgeons that have said don't give blood. It's us that say don't give blood. Sorry to the surgeons in the room. But what is the definition of cardiogenic shock? You know, everybody talks about this. My nurse has always said, oh, it's a mean of 60. My thought in this is once you get a blood pressure less than 90, it's probably not good. All right? And you've got to figure out why it's not good. And that's, to me, no matter what definition you use, if the patient looks ugly, if they're blue or if they're pink and they're in shock, you're in trouble or the patient's in trouble. And so are you. But I always say take your own pulse first, right? So to me, the physical exam is still important. I live in an academic center for the longest time. And I would watch some of my attendings, not go in the darn room. And it used to bug the crap out of me because it's pretty easy to differentiate between cardiogenic shock and sepsis. Sepsis are warm and pink and hypotensive. And cardiogenic shock is blue and ugly and dying. Right? I mean, it's pretty simple. But if you don't go in the room and you don't feel the toes and you don't look at their knees all mottled, you don't know where you're going. So I think it's really, it's interesting. I had a lot of MPs, PAs. I had over 80 of them. And one of the things I always interview, I say, what's the worst patient you can take care of? And he said, and if they got it right, they get the job. They say, Dr. Hurt's a guy who has sepsis and her heart doesn't work. That is the worst patient. And when we talk about MCS, that's probably where you're really going to be able to use MCS to help the patient out. So I also want to talk about all the data you see is about acute MIs, a lot of the data. But you have to understand that not all cardiogenic shock, which I'm sure you all know, is not acute MIs. So I just think you always have to think about what else is causing this. It's easy when they went to the cath lab and they had a left main and they were in trouble, blah, blah, blah. But a lot of those patients, look, myocarditis and COVID, we saw all types of things. I have seen more Takotsubo disease in the last couple of years than I've ever seen in my first 15 years of practice. Of course, didn't know what it was when I first came out of practice. Nobody knew what that was. And also the other thing with refractory arrhythmias, they are really tough. If any of you have had a refractory, the V-Tach, V-Tach, V-Tach, V-Tach, V-Tach, V-Tach, those patients too are very tough. So you have to sit in your mind and you have to think, what is the cause of their cardiogenic shock besides this AMI? That's the easy one. It's all the others. And there's a lot of others. And it's interesting, if you're in an academic center, you see a lot of the others because the smaller places that, I don't know what's wrong with this guy. He's not having a heart attack, but boy, is he sick. He's in shock. So it's really important to figure that out. So I'm going to spend just a tiny bit of effort here on right heart failure to try to bang this home that not all cardiogenic shock is the left side. There's a ton of diseases now. We know that right-sided shock is pretty common. And you have to recognize this. And these are just some statistics. I mean, people with right, they have a heart failure with a reduced ejection fragment, almost half of them have right-sided heart failure also. That's really important to know. Always be aware of your inferior wall infarct and know how to diagnose pulmonary hypertension. And we'll get to that later and talk about the PAC. Because there's so many people out there that have undiagnosed pulmonary hypertension. And when you get them in the ICU, you don't think about it. And you actually have the echocardiographers oftentimes don't look at the pulmonary pressures. And you don't have any way of knowing that maybe this right heart's failing and you're in cardiogenic shock all because of the right side. I suggest if you want to learn about right-side heart failure treatment, this paper that I have up here is excellent. Excellent, excellent paper. Another sidebar, just real quick, if you're wondering if the kidneys are dying from right heart failure, do a renal vein ultrasound. I guarantee you if you see this or that on the renal vein ultrasound, that kidney is congested. And you've got to figure out a way to get unloaded. It's not because of the hypotension. It's because of the venous congestion. Just a quick slide. Look at the reference. It's great. All right, so let's talk about this. Let's talk about the Journal for Cardiovascular Angiography and Intervention, the FCAI whatever it is, diagnosis. I think it's kind of Mickey Mouse to be perfectly honest with you. I think the important thing, but it is nice. I think the thing you have to remember is that this does not tell you how to treat the patient. It tells you how to prognosticate. Big difference. So it doesn't say, at C, you're going to put an MCS in. Although I kind of was starting to believe that at C, you put in an MCS. And I'm not that biased to impellers or anything else. I'll talk about that a little bit later. But the bottom line is I think when you get the C, and if you see hypotension requires intervention, does not look, looks unwell. Extensive rails, clear glass, BiPAP, cold, clammy. All right, it's C. Let's do something. I think that's the important thing about this. I think as we go along and people use this more and more for research, maybe we'll be able to get to the point where it also says, okay, when you get the C minus one or C plus one or whatever they decide to do, do a device or do something else. So there's a lot of talk about this. It's okay. But the bottom line is, again, I go back to use your own common sense. You certainly know people die. I mean, when they're in that's DNA, look at the mortality rate. It's just, it just escalates immediately. So the other thing you got to watch out for phenotypes of different cardiac. So if you look at things like, we'll talk about CPO and pappy in a little bit, but you know, if you're aging, if you're over 71 years old, you have a lactate, we all know these things. You're, you're, you're doomed. And if you look at this other scale here, actually, somebody came up with actually a scale and they give you points. So if you're on pressures duration greater than 36 hours, you add these points. That was pretty quick to see that you're going to die. So you got to start thinking about, am I going to treat this patient or not? I'm not going to treat this patient. And I'll get a little bit more into that later in the talk, but right here, I'm actually, I'm sorry, I've moved the slide. This is kind of cool. This is called the miracle two. I don't know if you ever heard of this prognosticator, but it's kind of neat. It was done in patients who without a hospital cardiac arrest for immediate coronary angiogram. So they had outpatient cardiac arrest. They want to think, Oh, should I go to angiogram or shouldn't I? And this is fairly new. And there's also an article now called fall and the miracle two, which is about pooling patients and whether or not you should move ahead. But this scale is kind of neat. It's called the miracle two, and you get certain points and they get these certain points. You can see if you've got a miracle scale greater than four, it favors conservative treatment, which is kind of interesting, right? We don't ever really, we think about, Oh, is the guy going to wake up or not? But if you have these and look how easy it is to get four points. If epinephrine was given, you get two. If the pH is less than seven, two, you get one and changing rhythms, you get one, four. Well, that's four. So it's kind of interesting. I don't know if it's going to be completely validated, but I think it's something to put in your arm and terrium when you're, you know, sitting in your hospital and you're thinking, should we continue going with this guy or not? But that was conservative treatment. I want to go through some of the therapies y'all know about ECMO. I mean, echo. I mean, everybody should get an echo, right? But the problem with echo, and I know there's people just believe in these echoes so much. Echo to me is great. If you have a really good person to do it, how many times do you see the thing? Not good study. Can't see the right heart, which is really important. Can't measure a tapsy well. It's a great device in some ways, but it doesn't give you the answer. And sometimes it'll take you down the wrong pathway really, really quick. As I always say, an echo is a picture, a swan GANS catheter or a pack is a movie. And if you learn how to interpret that, it's very, very good. So everybody has a central line, right? Everybody gets a central line these days, right? So it's really important. If that CVP is greater than 12 and the SVO2 is less than 65, that patient's starting to be in trouble. Normal people do not have those numbers. Abnormal people have those numbers. And I think it's really important to look at your CVP and think about where am I going next? And if those CVP numbers are there, you're going with a swan. We'll get to that a little bit more. And always be aware of the V wave. I don't know how many times in my rounds I'd walk into a room and I'd see this. This is CVP with a giant V wave. You know what a giant V wave means? That tricuspid valve is wide open. You're in trouble. So is the patient. That patient is going to need some type of a device or something else done to them. And let me tell you, everybody talks about the onotrophs and right-sided failure. It ain't great. Miller-Rohn's okay for right-sided failure, but it ain't great. So you really got to think about how you're going to decompress the right side, which is kind of where everything is now. We're trying to figure that out. So the pulmonary artery, there it is. I don't know. The PAC got such a bad name, especially these pulmonary critical care guys. Sorry, I'm not a pulmonary critical care guy. I'm a critical care guy. But I got to tell you, the PAC just got destroyed by the FACT trial in ARDS. But nobody ever looked until just recently about the value of the PAC and cardiogenic shock. It is the best device you can put in a patient to figure out what the heck's going on and assess how your interventions are making the patient either better or worse. The problem is that when they first did this study, they did this study and they questioned a bunch of anesthesiologists and critical care docs. They got it all wrong. And even in my CSICU, we were doing 1,500 hearts a year. I still had a problem. I had to go into the room, level the transducers, tell the nurse what the hell the waveforms look, excuse me, what the heck the waveforms look like. It took a long time to get to that point. So I just want to make sure that you all know, I think it's part of your training. I had fellows six years out who did not know how to put a SWAN in somebody. I think that's a criminal event. You've got to learn how to do SWAN-GANS catheters. I think SCCM should have a course in just doing SWAN-GANS catheters. I got to move on. So here, complete and automatic profiling pulmonary catheters, really important. You can look at these slides later. The bottom line is, if you do a full assessment with a pulmonary artery catheter, including looking at the right arterial pressures, you have better survival rate. Contour analysis devices, you all have them. You know, the things you put in the radial artery. I suggest that you do not use them. I think they're completely inaccurate. If you're on norepinephrine and you have it in the radial artery, I guarantee you there's a problem. And there's lots of literature. If you really go into the literature and look at the comparison data between PACS and these devices, these devices do not match up. The European consensus in critical care says you can use them, but for God's sake, they've never been proven in shock. The way they were proven was in patients with hip operations who got hypotensive. Never been shown to be effective or accurate in sepsis or vasodilatory shock or cardiogenic shock. Just a bottom line on that. Again, just a little bit about how to look at the swine gas catheter. This is bad news, right? But know how to use your PACS. I'm going to talk about CPO real quick. It's really pushed. AbioMed really likes this. Everybody likes this. I think it's pretty much cardiac power is as strong as hemodynamic correlate to mortality. Well, no crap. Mean blood pressure and cardiac output, that's what we live by, right? I mean, come on. So if you get a normal mean and you have a normal cardiac output, yeah, you're going to do well, but it is nice. It's something that's really nice to track and how you're proceeding and how you're making the heart better because what it does, it brings. It's a coupled equation, but it works. I like this. This is an update on this. You take the right atrial pressure and add that in and think about that. As the right atrial pressure goes up, that number is going to go down quickly. So it's a really good, I think I always, I like to add the right atrial pressure. Again, I'm a right heart guy. I spent 20 years, 40 years of my life learning about the left side. Little did I know I should be learning about the right side and the echocardiographers are still trying to figure that out. I just want to say, everybody talks about SVR. Gosh, I tell every nurse in the world, do not talk to me about SVR because if you look at what really counts, that counts. Cardiac power and output counts. SVR, it's a coupled mathematical, you know, it's coupled. The bottom line is get your cardiac output and get your mean blood pressure up. And we all know, this is very interesting. I'm going to get into this real quick. Vasopressors, the more vasopressors you have, the worse it is, the worse your outcome is. There's a CPO. There's with blue is your one pressor, zero pressors, one pressor, two pressor. We know you have problems. You know, the one thing I can't quite figure out is why this and this are different. But, you know, the bottom line is I think you just try to get normal. And then, of course, the lactate, everybody follows lactates. I've had people with 20, you know, lactates of 10 or can't read who have survived. But, you know, you know, you're in dog deal when you see a lactate. Who doesn't know that anymore, right? And then what's the pulmonary artery pausatility index? This is all again about the right heart. Tons of trials that tell you that it's a good thing to do. PAPI, 0.9, RV is normal. Less than 0.9 is possible RV failure. It's time for ECMO or ECPELA or RP and PELA. When my right heart's failing, I'm dying because I am really struggling with that patient because now I got right and left. And it's really hard to manage those patients. And luckily, there's devices coming down that are going to help us a lot with RV failure. Considerations and indications for MCS, patient's hemodynamic, phenotype's really important, degree of support, vascular access and anatomy, pretty darn important. You got to know where you're going. You got to know what you're doing. Experienced operator, very important. All these are important. I think severe forms of CF, stage C and E, you're starting to think of some type of device. Listen, I practiced for 40 years. I said, oh, that damn PELA thing doesn't work. You know, it's caused bilirubin. It's really awful. But then afterwards, I started practicing and then PELA got better and better. I started saying, oh, wow, I'm coming off my onotrophs. I'm not banging the crap out of this heart anymore. You know, and I have actually been a convert. As you can see, I'm standing here, but I've become a much more of a convert for MCS. These are the different types. I just have to put that up there to show you. I think, you know, the right side and PELA RP is really nice. We're moving into the new PELA with the 5.5, which is absolutely tremendous. IABP, maybe yes, no, probably no. Hey, if you're a small hospital, put it in. I mean, come on, you got to do something. And that does help somewhat. I found, I still find, if I have wide open mitral regurge and a guy that's in shock, an IABP actually does help. There's no doubt. I think that's my number one indication for IABP. Whatever MCS that needs to be started, it got to start it early. More than one onotroph, you got to start thinking. Escalating pressure, CBP again, SVO2 again. When you get to the stage, purple and blue and not looking good and increasing onotroph. Don't forget the IABP data per pre-PCI. There's very good data for putting the IABP in right when you start your PCI if your heart's in trouble. That'll save you a lot of work in the ICU. That's one thing these devices have done. They have saved me a ton of calls because once I got them in, they're in. I have to move on here. So what is early? Here's some definitions, but if you wait too long, you're in big trouble. 26% mortality. And then again, the whole thing with onotrophs. The more onotrophs you add, the bigger you're getting into the hole. It's pretty common sense, right? There's the onotroph stuff again. I just want to say one more thing. A cardiac intensivist is really, really important to the game. And there's a good paper out there that just shows how important we are. Patient-required onotrophic patients for a cystic. So they had ICUs for a number of years that had no intensivist, and then they had a dedicated intensivist. Look at your mortality rates. Look what happens. So bottom line, it's kind of interesting. Some of this stuff like the dopamine and norepinephrine, you notice that they had a lot of dopamine in the group that didn't have an intensivist, not so much in a group that had an intensivist, right? We're supposed to use norepinephrine for cardiogenic shock or shock, not dopamine. So it just goes to show, if a person's there and knows what they're doing, it can help out. So the data speaks for itself. Best practices, you really have to identify shock early, use the right heart cath, learn how to use it. If you don't know how to use it, have somebody teach you. Make sure you know, not just putting it in is not knowing how to use it, it's knowing how to do the wave forms and everything else. Incorporating MCS, Impel is really nice for pre-seized PCI. I would just say, you know, go out there, form an intensivist team, really work together. You have to have a shock team and, you know, learn about mechanical support. Thank you very much. Whoa. See if we'll get me up and running. Are you guys able to hear me okay? It's a little bit loud out there. Thanks so much, Linda, for that introduction. Dan, thanks for kicking butt up here. My name is Eddie Gutierrez. We're gonna be talking about cardiogenic shock, obviously. And you have your diagnosis. Yeah, cardiogenic shock. Okay, cool. Now what do we do with these patients? How do we get moving forward? Because unfortunately what happens is that patients get diagnosed with cardiogenic shock and then you're like, oh, let's just put them on a little bit of noradrenone, a little bit of dobutamine, a little bit of norepinephrine. But for every one hour delay of escalation that you don't fix the underlying problem, it's associated with a 9.9% increased risk of death. And this is something I show to my nurse practitioners because what happens is patient comes with a cardiogenic shock in the middle of the night and they just say, oh, let's just hold them over for the day shift for the cardiac surgeons to come in or for the interventional cardiologist to come in and put a device. By that time, patients are dead. Dan showed the data for that. For every bit of delay of care of these patients, they just die, unfortunately. Trying to learn this pointer here. Because again, as Linda mentioned and Dan mentioned as well, what we want to avoid in these patients is this death spiral that ends up happening. But the question is how should we go ahead and escalate on these patients? Well, the first thing we do is identify the patients. Again, what Dan mentioned earlier. And this is where we have to address the underlying insult. If the patient needs a left heart cath, that needs to be taken care of. If the patient needs a right heart cath, hey, we do that in our ICUs. I train my MPs and PAs to do it. We're all very comfortable at placing these devices. It didn't happen overnight, though. It took a little bit of time, but it is something that we do in our practice. And if the numbers don't make sense or if the numbers are inappropriate to sustain life, then we have to consider mechanical circulatory support. And this is where you calculate the CPO as well as the PAPI that Dan described earlier because these are gonna help you determine whether the patient needs left-sided support, right-sided support, or biventricular support. But you might say, okay, Eddie, all this stuff is nice and abstract and we'll take this back to our institutions, but are there protocols that could help guide us? Because we're gonna have to show this to the other physicians that we work with, our interventional cardiology colleagues, our CT surgery colleagues. We have to show them something to say, okay, this is the way that we're going to do it. And I know that this is a busy slide right now, but I'm gonna break it down and make it a little bit easier. But something similar like this document, which y'all can just take a picture of, I'll smile with you. These documents go ahead and provide you a template for which you could build your program for mechanical circulatory support and your shock team. Because the first thing we have to do is identify the patient who's in cardiogenic shock. Unfortunately, CMS has brainwashed us all to think everything is sepsis, right? Everything's sepsis, elevated lactate hypotension, sepsis, 30 cc's per kilogram. Heck, if that happens to our patients who are in cardiogenic shock, we know what the outcome is. It's gonna be awful. But what happens is that you find these clinical criteria, and this is where the physical exam that Dan mentioned earlier is very important. It's the patient, they're cold, but they're also hypotensive, and they also have an elevated lactate. So this is where we are, in theory, supposed to activate a shock team. Dan has a shock team. Dan had a shock team in his major academic institution. My institution, we don't have a shock team. They call it critical care, and then we take care of the rest. But a shock team should, in theory, bring together interventional cardiology, CT surgery, advanced heart failure. I don't have advanced heart failure. I am the advanced heart failure at my shop, as well as the intensivist. I do that too. Check off the boxes. And here we have to decide whether we need to take the patient to the cath lab, if it's cardiogenic shock secondary to an acute MI, or should we take the patient to the cardiac ICU and float a swan in the cases of patients with acute decompensated heart failure, myocarditis, tachysubas, all those other fun things that we take care of. And if the patient is deemed to have decompensated heart failure-based cardiogenic shock, we float a swan. We need to know what these numbers are. We need to appropriately treat these patients and their hemodynamics. The other thing we obtain in the patients is an echocardiogram. We have structured a way in our facility to get echoes done 24 hours a day by an echo tech. The good thing about that is that usually I have the echo tech get the baseline echocardiogram on the patient and I see where they put the probe so I don't have to spend a bunch of time and I'm not as good as they are, but at least I know where the windows are and I put a little X on them. I'm just kidding, I don't actually do that. But you take a mental picture of where you get the best windows and you manage the patient from there. If the patient's in cardiogenic shock secondary to an acute MI, well this is where you have to activate the cath lab. You have your IC guy come in. They're gonna go ahead and squirt the coronaries. They're gonna also do a right heart cath. That was hard initially to get them to float swans in patients, but once they saw the reimbursement they got a little bit happier about doing it. And they're also going to assess the peripheral anatomy to see if somebody's a candidate for some sort of mechanical circulatory support device. And this is why you need your swan. You need to know what your hemodynamic criteria is for the patient. You wanna know what their cardiac index is or cardiac output, but you also wanna calculate the CPO and the PAPI. Without these particular factors you're kind of flying blind in the management of your patients. Okay, and if your hemodynamic criteria are met this is when you go ahead and you say, hey, we need a device for this patient because putting these patients on jet fuel is not gonna be enough to actually sustain life for them. And this is also going to be very helpful to identify if the patient has left-sided cardiogenic shock, right-sided cardiogenic shock, or biventricular shock because that helps you decide what device you need to manage this patient. So for example, somebody who has left-sided dominant cardiogenic shock, their CPO is gonna be low, their PAPI is gonna be okay, their right atrial pressures are going to be low and their wedge pressure is gonna be elevated. And somebody who has RV dominant cardiogenic shock, which is something that I agree with Dr. Herr about, is definitely under-recognized. I mean, this is where your PAPI is going to be your go-to measurement. But one thing I do have to say about the RV dominant cardiogenic shock is that the PAPI in some literature is defined as being less than 0.9 and in some literature it's less than 1.0. So your market may vary as to what number you use for your particular cardiogenic shock program. And if the patient has biventricular shock, well then they possibly need two devices or VA ECMO to help them out. So once you go ahead and do put these devices into the patient, they get to your ICU and this is where they fall into the hands of the intensivist. And this is where we're gonna be doing daily bedside echocardiograms. I have to admit, I do more than one echocardiogram on my patients per day when they are on support. You wanna do frequent neurovascular checks because unfortunately people do have ischemic legs from time to time and they also stroke out from time to time. I'm gonna go over the data for that soon. And you wanna be doing serial checks of the CPO, PAPI, lactate, other labs, which I'm going to be describing for you all shortly. And you always wanna be thinking about whether you're able to win the support or what your exit strategy is gonna be in case that they do not survive or they do not do well on the current device that they're on. So always have a good palliative care conversation with these patients and their families because mortality is not the best. So you say, okay, this is a cool protocol, Eddie, but do these actually help with the management of patients? And we have to go back to remembering that the data for prognosis of patients with cardiogenic shock is that these patients carry a 50% mortality. Okay, right off the bat, 50% mortality. And we've seen that historically with data from 1973, showing that 83% of patients pass away with cardiogenic shock. And then all the way up to 2016, we're still seeing that 50% mortality. That's honestly unacceptable. But once they started implementing protocols similar to the one I just described earlier, we found that the mortality rate dropped to 28%. So far more patients were surviving cardiogenic shock with the utilization of these protocols. And in the case of the Detroit Cardiogenic Shock Initiative, what they found is initially that center had a mortality of 50%, like everybody else did, right? But they found that by implementing these protocols, their survival was 85% and their discharge home was basically 75% survival. So from 50% to 75%, that's a pretty substantial improvement. And this was the algorithm that they used in this particular trial. And they have an inclusion and exclusion criteria, which I'm not gonna go over, but if somebody has an oxygen brain injury, obviously don't spend the money on doing all this. But their key point for us intensivists is to go ahead and calculate the CPO and the PAPI in these patients. As a matter of fact, Jago got pissed off at us, part of my language, because we initially had this on the wall in our ICU, but they said, oh, you gotta laminate it. And I'm like, okay, fine, we'll laminate it. But we actually have this up on our wall, so all of our nurses in our CVICU and CCU are familiar with the protocols and what we're trying to achieve for our patients. So you get this patient, you put an Impala in them, you put a device in them, and the first question that people always ask is what should we do with the vasopressors and inotropes? And the reality is you wanna try to peel them off as soon as possible. Remember, this is gonna increase your myocardial oxygen consumption. They're not physiologic, so you wanna try to wean them down. If you're not cutting it with the device that was put in, well, they need a stronger device, to be completely honest with you. But again, further emphasizing how much better we're doing with the implementation of these protocols. Again, historically, 50% survival, and this has increased to over 70% with the utilization of these protocols. So definitely something worthwhile for you to take to your institution and hopefully better your outcomes from cardiogenic shock. So enough about all this stuff. Let's actually go ahead and take care of these patients with cardiogenic shock. That's what we're here to do, is actually learn how to do this. And one of the first things we do is actually unleash the order set. You know, we built this into Epic, we built this into Cerner when we had it before. But bottom line is that you wanna do serial labs on these patients. You wanna be able to identify if they're going downhill before they actually sometimes present clinically. So that includes doing a serial CBCs, Q4 to six hours, depending on how critically ill the patients are, BMPs, lactate, check LDH or plasma-free hemoglobin, I'll go over that in a second, as well as PTT or ACT, depending on if you're gonna anticoagulate your patient or not. And amongst the daily labs, you wanna do LFTs, PTINR, for example, MAGFOS, things of that nature. But it's very important to do imaging on these patients daily. That includes a chest X-ray, it helps determine the position of the patient, not the patient, but of the actual device in the patient. And you also wanna do TTEs on these patients. You wanna make sure that the device is not migrating in any way, but you also wanna see what their LV is looking like. So I personally do echocardiograms on my patients every single day. I have an echo tech come and do it first, and then I do it myself during the course of the day, especially if I'm titrating up or down on the actual P level on the device. So when the patient actually arrives to the intensive care unit, we should be there at the bedside to receive handoff from the staff in the cath lab if they got it done there versus the OR for the 5.5s. But anyway, first thing you gotta do is check the insertion site on the actual patient's body. If this is a device that's placed in the patient's groin, it's emphasized to put a little cotton swab or a little bit of gauze underneath so you can hold it at a certain angle. And this is a patient of mine who I took care of right before coming over here a couple days ago. This is a 5.5 Impala centrally placed in a patient who just underwent cardiac surgery. You also wanna check the extremity, make sure it's warm, make sure it's perfused, make sure they have pulses, make sure they can feel it. All these things are important. And you also wanna check where the device was locked because unfortunately when patients are moved from stretcher to bed or vice versa, there is some change in the position of the device from time to time. You also wanna make sure what the patient's baseline P-level purge flow and the Impala flow is. To those people who are not familiar with what the purge flow is or what the P-levels are, definitely invited to go talk to that man right there. And he'll tell you everything about the P-level over at the booth. What number is it? One, two, three, one? One, two, three, one, over there. And he'll definitely explain to you and you guys could play with the device, et cetera, et cetera. But also check a chest X-ray. You wanna review the waveforms. As Dan mentioned, your PA catheter is not valuable unless you actually have it placed correctly with the correct waveforms. And you also wanna do the echocardiogram that I emphasized before. But not everything is sunshine and roses with the management of these patients. You have to have your eyes open for complications that potentially will arise, statistically speaking. And the most common, historically speaking, the most common complication that was seen was bleeding. And there was a systematic review and meta-analysis that was published in December of 2020 that showed that up to 20% of patients had bleeding complications from these Impella devices. Thankfully, more recent data, for example, the RESTORE-EF trial that was published this summer showed that only 2.5% of patients are now requiring blood transfusions. So we've gotten better at this complication. And then the PROTEC-3 trial, which was also published this summer, showed that less than 2% of patients require blood transfusions. So with any new technology, as the time passes, we end up getting better at managing them and therefore we have fewer complications. I'm also gonna discuss purge solutions because this was one of the reasons why people bled so much. The purge solution is basically what keeps the device from not clogging up, for lack of a better term. And historically speaking, the purge solution that was most commonly used was heparin. And depending on the institution, you might have a different protocol, whether you wanted to do a certain, you wanted to shoot for certain PTT or ACT targets. It just became kind of a mess. But more recently, we've learned that we could use bicarb as the purge solution, and now this is supported by data, to keep our pumps from actually thrombosing, right? And very recently, there was a trial that was published just a couple months ago, which looked at whether or not there was a difference between pump thrombosis in the group that received heparin versus the group that received bicarb, and there was no difference between the two. So something to keep in mind. But also, a key factor is that there was less bleeding in the groups that used bicarb instead of heparin. So if you guys have a lot of bleeding complications, this may be a way for you to mitigate it at your institution. Another complication that does unfortunately take place is hemolysis. I mean, we are running these patients' bloods through pumps. And that is something that is seen in about 10%, 10 to 11% of patients, also based on the systematic review and meta-analysis. And one of the ways that we could try to catch this ahead of time, at least in my institution, is that we do serial LDHs on these patients. Some institutions use plasma-free hemoglobin. Does anybody here use plasma-free hemoglobin? All right, all you guys are lucky, but that's not the majority of hands, though. That's why we're gonna talk about LDH first. But if you do find that your patient is having hemolysis, the first thing you should do is assess the position of the device. You already know where it was locked. If you've been doing your own echocardiograms, you can put the probe on the patient's chest and have a quick look. You wanna make sure that the fluid status of the patient is appropriate. You wanna make sure that they're not dry, for example, which is something that does happen from time to time. From a management standpoint, you wanna decrease the P-level on the actual device. But in some cases, you may have to actually escalate your device to a five-five if you have it available to you. Okay, and certain algorithms exist, which I'm just gonna quickly go over. But first thing, you identify hemolysis. First thing you do is to check an echocardiogram on the patient, make sure the positioning is okay. If the positioning is not okay, well, then you fix the positioning. It's not rocket science at the end of the day. But if the patient does have persistent hemolysis despite the repositioning, you gotta continue your whole troubleshooting algorithm, which we will do now, which includes looking at the patient's volume status. If the patient's LV is empty, well, then these patients need a little bit more fluids in some cases. So if they still have hemolysis despite optimal fluids, a fluid resuscitation, you need to continue troubleshooting, which takes you down, possibly fully anticoagulating the patient to avoid this hemolysis. But if the patient is still anticoagulated and they're still hemolyzing, you have no choice. I mean, you have to bail with the current device that you're on and escalate to something else. In this case, the recommendation is to use a 5-5. And there is data looking at this escalation using, for example, the LDH that I have at my institution, where you see that the LDH levels are elevated. But as you go ahead and change the device from, for example, a CP to a 5-5, you do find that the LDH is dropped on these patients. If you use plasmodium hemoglobin, you have the advantage of that dropping down faster. You don't have to wait the 24 to 36 hours for it to drop. And you're able to see a quicker response with regards to your marker for hemolysis. This was a patient that I took care of just a couple weeks ago, over the course of Halloween. And on Halloween, he gave us a scary present that he started hemolyzing. If you can see, the LDH just shot on up. So what do we do? I called my friendly neighborhood CT surgeon. We changed him to a 5-5, and he dropped back down to, not quite baseline, but he did drop down substantially. Another complication we need to watch out for is limb ischemia, because that takes place in about 5% of patients. So as Dan mentioned before and emphasized, touch your patient. Make sure you're getting pulses, check Dopplers, whatever's necessary. Also, don't forget to do neurochecks on your patients, because we do see CVAs, five more minutes, in about 4% of patients. There are certain alarms that take place. For example, they're always very scary. The most scary one is a suction alarm. Whenever the machine goes off with a suction alarm, which Jason will go and replicate back there, everybody kind of freaks out. But let's just make this a little bit more simple. The machine will tell you what you should do to take care of these patients. For example, I put it there, you see the yellow arrows. That means that, you know, you have a suction alarm. It's going to tell you to reduce the P-level, look at the filling pressures and volume status, and then you want to check your impella position. But what causes these suction alarms is something we should worry about. Number one, inadequate LV filling. The patient's dry. You want to make sure that their volume status is appropriate. Incorrect positioning, that's why you're getting daily echoes on these patients, and that's why you already have a mental note of what the position is of the actual device in the patient's heart when, you know, you put it in your memory box of sorts. And also, you want to make sure that the patient is not going into RV failure. This is why you use your PAPI every six hours, because if that's the case, you start noticing that their PAPI starts dropping. Hey, you're in RV failure, you need to do something about that. But the thing is, you shouldn't just let it ride, because some people have suction events here and there, and you're like, ah, it went away, and you really shouldn't do that, because you're going to note that the patient's not going to get the right flows. They're also not going to receive the benefits of the device, and third, you increase the likelihood that they're going to start hemolyzing. So if you have these suction events, adjust them. So let's go ahead and fix these suction alarms. First thing, reduce the P level that you have on the device. You're going to, again, check your volume status and your filling pressures, and reposition the impella if needed. These are the normal waveforms that take place. You have the aortic waveforms, which are noted in red. You have the left ventricular waveforms, which are up here in gray. And then you have your normal motor current waveforms. For example, for the CP devices, you'll notice the motor currents are pretty high. They're in the 900s, 800s. If you have a 5.5 impella, that hangs out between the 400s to 600s. Just a little refresher there. But what happens is that, in this case, this is something called diastolic suction. And what you see is, you see this little change in the left ventricular waveform, and you notice that their diastolic pressure on the left ventricle starts decreasing. And this is, again, what's called diastolic suction. This is where you need to go and look at the CVP on the patient. If the CVP is low, chances are they need fluids. But if the CVP is high, then these patients likely are going to RV failure. You need to do something about that. You're also going to have your papi telling you about this. In this particular case, this suction alarm is going to be continuous suction, where you see a decoupling of the aortic waveform from the ventricular waveform. And in these cases, you need to check the positioning. It's up against the wall. It's up against something that it's not supposed to be up against. Other times, the machine is going to tell you exactly what's going on. Here, you can see that the LV waveform is completely over the aortic waveform. So what's happening? The impella's in the aorta. Pretty simple. Move it. Fix it. And then bill you for your CPT code for that, because you get reimbursed for that. Here, the device is entirely in the left ventricle. So the device is going to tell you it's in the left ventricle. You just put it where it needs to be. You also find this particular alarm that's called low pulsatility. In these cases, what you find is that the aortic waveform is not very pretty looking, and the left ventricle waveform is not very strong. First thing you should do is just chill out for a second and make sure the patient looks okay. If the patient looks okay, it's just that their native cardiac output is extremely low, and you just need to wait for them to recover. That's the whole purpose of the device. But if the patient looks like doo-doo, you gotta run, okay? That's pretty straightforward there that this patient likely needs escalation of care. So do an echo, assess the volume status of the patient, et cetera, but don't necessarily freak out unless the patient looks bad and they're hypotensive, et cetera. So this is where you get the low pulsatility alarm. So, okay, we went over all these alarms. Let's figure out if the patient's being adequately supported or not. And this is where the physical exam comes into play. As Dan mentioned, if you're all of a sudden coming down on your basic pressure and anatropes, their mean arterial pressure looks good, their mixed venous looks good, their CPO PAPI looks good, urine output, hey, we're doing well with that. This patient is adequately supported. And one of the things about the device is that now it has the ability to measure the CPO on the actual device itself. There are a couple menus that you could go through. Jason will go and show you over in the booth. One, two, three, one, correct? And it could basically tell you what the CPO is so you don't have to divide by 451 because I can't do that in my brain. So if our patient is struggling, when do we need to escalate? Again, touch your patient. If their physical exam doesn't look good, if you're not making any movements in the right direction with regards to the vasopressors and anatropes, they're still hypotensive, their mixed venous looks bad, CPO and PAPI are in the gutter, you need to do something to help out this patient because the device you currently have is not quite cutting it. But you always have to know your institutional limitations. So for example, my institution, I don't have ECMO. So if I need a patient, I need to put a patient on ECMO, I need to call another shop in my community and thankfully we have a fantastic relationship and they'll take any person as long as they have a pulse and help me out there. But the thing is, you never want to call them when they're already dead. You want to give them a good heads up so they could get you a bed, et cetera, et cetera. Always phone a friend. Make sure you have other institutions that could help you and have your exit strategy teed up. Usually three to five days with the device to see if the heart does get better. If it doesn't, hey, then they need a transplant or a durable LVAD. But always have that palliative care conversation. So let's have a quick success story. How should we deescalate? Q6 hour, CPO and PAPI. If those look good and they're off of all the jet fuel, then chances are you're gonna be heading in the right direction. And you put them on P2, if they're CPO, PAPI, all this stuff kind of gets, it kind of becomes muscle memory to keep on reviewing on these patients. Their organ dysfunction is better, off of vasopressors and inotropes, and their daily echo shows improvement. Hey, then you could go ahead and get rid of the device. There is this particular screen, which one of the key points that I'm gonna show you is Jason will go ahead and show you back there how to get to this particular screen. But when you see that the patient's native cardiac output goes over the actual impella flow, then you can really think about taking out the device. Especially if they have a stable CPO as well as cardiac index. This is a patient of mine who was already on P3. I was winning him down. His native cardiac output was four. His impella flow was 2.3. And that's me in the background. Because I actually take care of my patients. This was a dude who I took care of, had a huge MI, EF of 10%, put a 5.5 impella in him, did a four vessel CABG. Here he's walking with a 5.5 impella. He did great, he went home. This is a 49-year-old dude, severe aortic stenosis. Showed up to the hospital because he couldn't work anymore. This was his echocardiogram. His EF was about 10%. Put a 5.5 device in him, did the aortic valve on him. He bled a lot after the surgery. Are you like finding something away? Oh, a gnat, okay. I thought he was like telling me like it's a small gnat or something. Anyway, so this guy bled a lot overnight. He got a ton of blood products. And what's interesting is that, yeah, he has a huge pleural effusion there. But look at the right side of the heart and look at the left side. The left side is like empty and the right side is huge. So overnight, the patient's papi hit the trash. CPO was also looking pretty weak. And the CT surgeon says, hey, Eddie, do I need to put a right-sided device in this patient? I said, give me two hours, put him on a little bit of milrinone, a little bit of Flolan, and he ended up turning the corner. It was just a temporary little thing, but we were ready to deploy the RP impella on him. But he ended up doing extremely well, went home, didn't even have to go to a rehab or anything like that. He did fantastic. So this is something that we're doing a lot is these high-risk cabbages in my CVICU. And they're a lot of fun to take care of. So after the impella is removed, what do you do? People always worry about, when are you gonna take out the actual PA catheter? I like to leave it in for 12 to 24 hours, depending on the patient, because I wanna identify if they're gonna crash or not. I mean, that's just something that you do all this work to get somebody out of cardiogenic shock. And you wanna make sure you don't miss the boat and you don't miss them potentially decompensating again. And so, was that 22 minutes and 30 seconds? On time? All right, sweet.

cardiogenic shock

management

protocols

patient outcomes

early identification

catheterization procedure

hemodynamics monitoring

complications

optimizing patient outcomes