Gregory R. Giugliano, Director of Inpatient Cardiology Services at Georgia Heart Institute, discusses cardiogenic shock and the role of mechanical support at the first inaugural Heart & Vascular Symposium hosted by Georgia Heart Institute at Chateau Elan Resort & Winery in Braselton, Georgia.
We're gonna move on to the next talk. Then I'm going to now introduce Greg Giuliano. He is the medical director of inpatient cardiology at Georgia Heart Institute and he's going to talk to us about cardiogenic shock and the role of mechanical circulatory support. Thanks Angela. It's my pleasure to represent G H I here today and special thanks to Dr Sam OD for bringing me down here six months ago. Um It's my pleasure to be here today. I'm gonna talk to you about cardiogenic shock and some sobering statistics. Again, another sobering statistics discussion. Here's my disclosures. So cardiogenic shock has a myriad of ideologies. As you can see on the left side of the screen, the most commonly talked about is acute M I and the C quella of LV, dysfunction. One thing in common to all of these ideologies is they all lead to a primary cardiac dysfunction and that primary dysfunction leads to poor cardiac forward output lactic acidosis, a cyclical spiral of inflammatory markers, inflammatory reaction, hypo perfusion vessel constriction and this cycle spirals downward, very rapidly culminating and death. Unless we intervene and break the cycle early, I'm gonna present an unusual presentation, not the classics Demi case because I think you're gonna hear that in a couple other talks. So this is a 45 year old woman who had really no medical problems. She injured her left knee a couple of weeks previously and was at home with her husband was a little short of breath and hand her husband witnessed a single pole episode. Um she was conscious at the time he called 911. Um E M S arrived very quickly. There were only about two minutes from the hospital emergency room and this is the initial E K G in the field showing sci tech cardia. You can see some inferior ischemic changes in complete right bundle. She does take oral contraceptives at home. She's a nonsmoker which is clinically pretty important. Um And in the two mile two minute trip from home to the emergency room, she had recurrence of chest pain, worsening dysosmia and started to get confused. Um They were unloading her from the ambulance and she dropped her sats into the eighties on a non rebreather as they're wheeling her through the ambulance bay into the emergency room. As soon as they transferred her onto the bed, she promptly had a P E A arrest probably hypoxic. It was bradycardia, Brady down a narrow complex and and lost a pulse. They did C P R A C L S protocol for about five minutes and recovered her. Um She promptly had three more very similar events. Uh She ended up on high dose epinephrine and norepinephrine drips required to maintain the blood pressure. So I don't think there was too much question as to what was going on with this woman. Um They did a quick bedside echo after the resuscitation. And I think even if you don't read echoes, you can look at this and see there's not a whole lot of movement here and this is by ventricular LV and RV function down with septal bowing. Um The presumption was a big P. She was just too unstable to do any of the modern therapies of acute intervention for pe being on high dose strips and for cardiac arrests in a short time. So she was given T P A in emergency room while they were administering the T P A. A multidisciplinary consultation was called involving cardiac surgery, vascular surgery, critical care, medicine, and interventional cardiology. And it was pretty much universal agreement that this patient in order to survive, needed advanced mechanical support. And she was immediately transferred to our Gainesville campus on arrival there. She was uh already preplanned ECMO team on site and she was placed quite quickly onto V A ECMO from femoral calculation which stabilized the situation. Several hours later, she did get A C T A and it did not show any evidence of a saddle P probably broken up by the T P A at this point, but there were peripheral mbali Her hospital course was actually pretty rapid recovery. Overall, she was eventually de escalated off of the, she was Decani elated by hospital day four as is typical with ECMO runs, there was significant bleeding. This one was special because she had gotten T P A which which led to even more bleeding. The course was complicated by Hepburn induced, thrown beside a pina. Um And due to the inability to give anticoagulants, she ultimately had an I V C filter placed. Um she had incredible recovery quite quickly within two weeks of her D cancelation. And so now you can see good RV and LV recovery. So here are the sobering statistics in the top left and this is a cue to my patients now to transition in the top left. You see that um the number of cases of cardiogenic shock associated with stem E is on the rise. The patient population we see presenting now is older with stem E and older with stem ian shock. So it's more complex. What have we done over the last two decades to improve that. And the answer unfortunately is we haven't found many therapies that actually impact this primary PC I we know is important, But we still have a residual mortality somewhere in the 30-50% range. And in hospital mortality is that and we have an ongoing mortality problem. Even in those patients who survived the hospital, stay out to 30 days and then out to a year continuing to worsen. And you see the problem to study this population in the bottom, right. We have a bunch of trials and we can enroll enough patients. Patients are too sick to randomize and it's too sick. A cohort to really glean anything from. So we have pioneers in the field and, and this is a slide from Naveen Kapoor who is out of Tufts in Massachusetts. And he really put forth a theory that, that pushed the envelope a little bit. And I think that's what we need. Um, that envelope was we need to actually identify the patient in shock earlier. We need to institute mechanical support earlier and we need to unload the ventricle and, and he is actually pushing for doing this prior to opening and included vessel to get the support stabilized, open the vessel. And that is a, is a different theorem that really has issues with equipoise in a lot of people's minds and something that is being studied now. So I summarize what, what Naveen put forth in this slide. I mean, if we don't know what we're dealing with and what's in front of you. Um It's, it's a very quick spiral and you get pounced on and the and the patient suffers. So our support options, there's a lot of support options. I'm just focusing on the Per Catania's ones that, that most of us have available balloon pumps in Paellas, you saw a case this morning supported by in Pella. Uh there's a right sided impel a device, there's tandem heart which requires a trans septal puncture. So it's a little more complex to deploy. And there's V A ECMO, which was done in the case that I presented. How do you figure out which uh device to use? Well, local expertise is important. What you have locally is important and then you gotta figure out complications, access sites. How much support do you need? What is your out if I'm gonna use one of these advanced therapies, does this patient ultimately a transplant candidate or is this really just short term uh support? So a lot of issues and you really need a team to figure that out a shock team. The S C and I is just one group that has put out a study looking at uh really futuristic protocol and it does incorporate Dr Kapoor's philosophy of unloading the ventricle first. So this is a study that was 4.5 years in the making. It ended about a year and a half ago and enrolled roughly 400 patients who had acute M I induced cardiogenic shock. And the protocol was interesting because if you try to set up inclusion criteria for shock, you have to, first of all get patients within 12 hours of their stem E and then this trial took on the patients at the highest most advanced levels of shock, including stage the shock, which I've outlined for you on the bottom of this slide, which is really beyond advanced shock and this is sort of pre morbid shock patients. So this included these types of patients. And the protocol went like this stem E cath lab activation as a standard access in the groin and immediate placement of support. And typically this was in Pella, followed by opening up the occluded vessel and then performing a right heart cath to determine based on two simple measurements, cardiac power output and the pulmonary pulse civility index. And based on those two measures you determine need for advice, additional escalation of left sided support or right sided support. Here are the outcomes. Now, this is not a randomized study, this is registry and you can see that procedural uh survival was very good actually, um almost nobody died intra procedurally to discharge. You had more than 70% survival in the overall cohort and even in the sickest patients, 54% survived. Now, you see this dramatic drop off at 30 days and that one year and what's going on there, that's the area for additional improvement. Those are the people whose LV functions are not recovering and those are the people who heart failure ultimately uh takes their life. So I wanted to give a plug for supersaturated oxygen therapy. It's one of the few therapies we know about in the last 20 years that actually reduces infarct size, okay. And this is delivery of supersaturated oxygen through a catheter. After re perfusion for acute M I, it helps because it prevents re perfusion injury from ischemic radicals. It helps deliver oxygen to the ischemic muscle and prevents permanent damage that uh we can't recover. After the fact, we have two clinical trials going on across the country now studying supersaturated oxygen further. And we have the pleasure of entertaining both of these at Northeast Georgia. Um One of them is in large anterior my population um which is standard of care. We're gonna open up the artery first thing and then deliver supersaturated oxygen and compare that with control to demonstrate these benefits in a larger population. And the is a shock trial is interesting. That's the Naveen Kapoor influence and that's gonna be patients with intermediate and shock implanting an impeller first to stabilize and unload the ventricle, open the vessel and then give supersaturated oxygen. Um It's a very interesting concept. I think there's a lot of complexity that goes into it and it's gonna require a highly skilled lab. Um And I hope we're gonna be able to offer that here to uh to the Gainesville area in Northeast Georgia community. Um This was mentioned previously and I think we really want to go back to this. Um And that is heart attack awareness about 22 years ago. I think the H A N N E N H L B I put out this awareness campaign to the communities about heart attack symptoms. And I think we need to revisit this because if patients get to us late the horses out of the barn and if the muscles already beyond recovery, no matter what we do with these advanced therapies, we can't recover it. So this is really essential. And I think you heard it echoed early on. We've got to get the patients in the community aware. In conclusion, cardiac cardiogenic shock clearly is a lethal epidemic, mechanical support for shock is redefining the treatment paradigms if as I've showed you shock protocols and shock teams are the wave of the future and they have shown promise and you're gonna see a lot more of them and hear a lot more about them. New therapies like supersaturated oxygen and timing of M C S are being studied. And I hope to be able to give you more in the next year on the results of that study. Thank you.
