Discussion Video: Management of Cardiogenic Shock in CCU
Managing Impella Patients in the CCU
Dr. Joseph Parrillo, Dr. Brian Porvin, and Dr. Steven Keller discuss managing AMI cardiogenic shock patients in the CCU with Impella®. The discussion covers several key management topics:
- Management of pressors
- The importance of invasive hemodynamic monitoring
- The use of echo for Impella placement to reduce or minimize the risk of hemolysis
- ECMO and Impella and how they might be used together to optimize outcomes
When asked how their institutions approach the use of vasopressors in a patient in cardiogenic shock who is being managed with Impella, the physicians discuss the hemodynamic targets that indicate that flow is reestablished and vasopressor support can be down titrated. They agree that the primary goal is to offload the left ventricle and decrease the pressure that the LV and Impella must work against to restore systemic perfusion.
All 3 physicians acknowledge a growing recognition of the importance of invasive hemodynamic monitoring in patients in cardiogenic shock who require Impella for hemodynamic support. Dr. Porvin mentions following the National Cardiogenic Shock Initiative best practices. Dr. Parrillo recognizes that some cardiologists and intensivists remain reluctant to put in PA catheters, but he emphasizes the importance of the data gathered from invasive hemodynamic monitoring. “In certain patients, if you don’t know what the hemodynamics are, you’re not managing the patient optimally.”
With regard to Impella repositioning, all 3 physicians agree that intensivists are typically very skilled in determining Impella position with bedside echo and most are also comfortable repositioning the device. Dr. Parrillo describes a team approach to repositioning, noting that he sees cardiac surgery intensivists as the experts when it comes to repositioning the Impella device while the interventional cardiologists are the experts when it comes to initial Impella placement.
Regarding AMI cardiogenic shock patients treated with ECMO, the panel discusses the growing use of Impella as a strategy for transition and unloading the left ventricle. Dr. Keller discusses the potential to restore normal perfusion patterns if able to get patients off ECMO and onto isolated Impella support. He mentions that strategies for limiting complications of ECMO support are gaining traction around the world and that clinicians are discovering the advantages of dual mechanical support.
When asked about using Impella provisionally or routinely with ECMO, Dr. Keller describes the strong physiologic argument for early, up front LV unloading to promote cardiac recovery. Dr. Parrillo emphasizes that if patients are going on ECMO, it’s wise to unload the ventricle. “Because the assumption is that if you reduce filling pressure and empty the ventricle that that’s hemodynamically better, particularly in the ischemic patient.”
- Cardiogenic shock initiative
- Intensivists perspective on Impella patient management
- Considerations for Impella vs ECMO
To learn more about the Impella® platform of heart pumps, including important risk and safety information associated with the use of the devices, please visit: www.protectedpci.com/indications-use-safety-information/