Dr. George Vetrovec:
Hello, and welcome. I'm Dr. George Vetrovec, Professor Emeritus, Virginia Commonwealth University in Richmond, Virginia. This is one of a series of short webinars aimed at discussing important topics and issues relevant to the interventional community, but particularly focusing on heart recovery relative to cardiogenic shock and we're going to be talking about several cases here and I'd like to welcome my co-contributors today, Dr. Bryan Kluck and Dr. Gautam Kumar. Dr. Kluck is an interventional cardiologist, endovascular specialist and vascular medicine specialist at Lehigh Valley Hospital. Dr. Kumar is an interventional cardiologist at Emory University. Welcome gentlemen.

Dr. Bryan Kluck:
Thank you.

Dr. Gautam Kumar:
Thank you.

Dr. George Vetrovec:
Can we see some cases Dr. Kluck?

Dr. Bryan Kluck:
I would love to show you some cases. This George and Gautam was a very bad afternoon for me, as it turns out. So I'd like to tell you the first case in the middle of the day was a 51 year old gentleman with really no prior cardiac history, he was found down on the front lawn of a lady who really did not know CPR. The patient normally jogs to his gym and was on his way there. There was no bystander CPR performed, on EMS arrival he was found to be in a shockable rhythm. One shock converted him from VF to sinus rhythm, ROSC was achieved. He was intubated and sedated in the field.

Dr. Bryan Kluck:
He was unresponsive, he had some spontaneous movements. As I mentioned, he was intubated. The rest of his exam was quite unremarkable. Here is an electrocardiogram and you can see that there's really no clear acute myocardial infarction on the tracing, he came to the cath lab and you can see he has a high grade stenosis of his left anterior descending coronary artery, is right is okay and you can see it's a complex lesion well away from the mainstem with a number of diagonal branches involved.

Dr. George Vetrovec:
So, you were very aggressive about taking him to the lab for angiography. But then, your institutions published some paper on deciding about when to take them to the lab. There've been some recent reports about when you should consider angiography, couple of comments here.

Dr. Gautam Kumar:
So I think this is a strategy that's currently being studied in the NHLBI sponsored access role, where you know if you have a V-fib or V-tach out of hospital cardiac arrest and you have no ST-elevations like your patient and it's being looked at in terms of early cath-lab strategy versus late cath-lab strategy. The result is still out on that and however, as we know, there are some more contemporary data on this as well. That was recently presented.

Dr. Bryan Kluck:
Yeah, I would agree. I think at this point still controversial. Our institution as adopted by and large a very aggressive strategy to this and by and large these patients are taken to their cath lab.

Dr. George Vetrovec:
And there was nothing really feudal about your patient either? That's another issue that comes up with these cardiac arrest, he had spontaneous movement early on and so forth. Any other comments that you would have Gautam?

Dr. Gautam Kumar:
No, I think this would be a great candidate.

Dr. George Vetrovec:
Great.

Dr. Bryan Kluck:
Right. We intervened a balloon dilatation and at the conclusion of their case, his hemodynamics were reasonable. His aortic mean pressure was 80, his left ventricular and diastolic pressure was 18, as we are want to do, we initiated a hypothermia protocol and no support was initiated. So, the interesting thing about this is, about halfway through this case, we got word from the emergency room that there was in fact a second patient who was found down, and so we spirited this patient out of the cath lab and moved along to the second case, which was in this case, a 64 year old gentlemen with an unknown past medical history.

Dr. Bryan Kluck:
He was found down in a campground and in this particular case, bystander CPR was initiated. EMS arrived, he was in a V-fib rhythm. He was shocked several times and once again ROSC was achieved. The patient was intubated in the field, he was sedated, he had ketamine initiated, aspirin was administered and delivered in the field. His electrocardiogram on arrival to a LAD demonstrated a significant ST segment elevation in the anterolateral leads. He was loaded with aspirin, he was loaded with Plavix and heparin and he was sent to the cath lab.

Dr. Bryan Kluck:
Again, intubated but in this particular case he was somewhat responsive and the remainder of his exam was quite normal. Here you can clearly see the difference where this shows a dramatic ST segment elevation and the effected leads and you can see his LAD was quite trunk rated. Approximately the remainder of the coronary tree was reasonably free of disease including his right coronary artery and once again we went after the LAD, we got a wire across the lesion, we got a balloon across the lesion and at the point where the balloon was across the lesion, we had some reduction of flow, but after the stent was placed, we of course had no flow.

Dr. Bryan Kluck:
We administered some adenosine, we administered a little bit more adenosine and then still more adenosine and finally got to the point where we had TIMI 2 flow and assessed at that point his hemodynamics, is left ventricular function clearly showed a hit to the anterolateral wall. We placed an Impella based on his elevated hemodynamics. The salient feature of course is his elevated left ventricular and diastolic pressure. So this man then his hemodynamics improved rather dramatically. Upon arrival back in the CICU, I happened to look at our first gentleman and I noted that he was significantly hypertensive. His chest X-ray demonstrated profound pulmonary edema resulting in hypoxic respiratory failure and essentially severe pulmonary edema.

Dr. Bryan Kluck:
So at that point we turned and we brought the first case back to the cath lab and we placed an Impella at which point his hemodynamics improved. In the case number two, the CICU was a four day stay. He returned to the CICU for a bit of a glottic ulceration, but by day seven his echo demonstrate an EF of 45 to 50% with moderate anterior hypokinesis. He was ambulating without complaints on day eight and he was discharged to home on day nine. Case number one, the hypothermia protocol was completed. The Impella was removed on day two, he had satisfactory hemodynamics. Neurologic improvement continued through day seven, he was transferred to the step down unit. He was discharged again on day nine neurologically intact with a normal ejection fraction and in the office two weeks later, both his cardiac and his neurologic exam were stone cold normal. This is his day number one subcostal echo and this is his discharge day subcostal echo demonstrating dramatic improvement.

Dr. George Vetrovec:
That's pretty remarkable. I think both of these cases represent the ischemic ventricular fibrillation tachycardia type of presentation and these are the ones that are very recoverable, but that's dramatic recovery of the heart function that you see when he walks out of the hospital with a normal ejection fraction. Now, this is a little bit different than where things are going these days. Comments about where you see the strategies perhaps changing in approaches to these patients.

Dr. Gautam Kumar:
So I think there's been a lot of evolution with these strategies, especially with the concern for reperfusion injury and concern for significant need for unloading of these ventricles even prior to attempting PCI. I think the upcoming DTU trial and it pilot data which was recently presented, is very attractive in that regard.

Dr. George Vetrovec:
Right. My take away is that we've been seeing more and more data that shows that early unloading before reperfusion actually is associated with better outcomes and the shock databases that we have, and so I think that's where this is transiting from where you are at these particular cases to where the field is starting to evolve, but these are dramatic and remarkable cases. I have one interesting question to think about is if you had taken another angiogram after you put in the Impella, what do you think the flow would've been in the LAD and with unloading and how do you think that might've affected this slow flow that you had?

Dr. Bryan Kluck:
I think that's exactly right. And reviewing the case, I think that the slow reflow made me wonder whether I should have put the Impella in first. In these particular cases, it is a little bit of a three dimensional chess game because you're also cooling the patient or potentially cooling the patient and you wonder how the outcome is affected by any delay you might have cooling the patient afterwards. Now you can cool the patient during the case, but not as effectively as afterwards. Admittedly, even cooling has some questionable outcomes and we're still working through those pieces of data, but I couldn't agree more that after the slow reflow happened, I wished I'd had the Impella in first.

Dr. Gautam Kumar:
I think a lot of the message with these patients is, even though our door-to-balloon times may be short and there's been a progressive push towards shorter door-to-balloon times. The key message is there is a significant totally ischemic time where the patient's been at home for two, three hours thinking that this is gastritis, taking Tums at home and that part of it still remains a significant issue and that actually impacts reperfusion, that late reperfusion can drive up the LVDP and that can then impact slow reflow.

Dr. George Vetrovec:
I'm glad you mentioned that because there's a German study that looked at first medical contact and the patients with shock, that's a very important factor in terms of outcome. You're going to have huge impact by shortening that time and any strategy you can get them in quicker in the lab and then with the consideration for early unloading before reperfusion, I think we're really trying to salvage that time as best we can. I know Tanveer Robin and at Emory has written an outline on kind of deciding who goes to the lab, not so much from the standpoint of should they go to the lab with cardiac arrest regardless of the EKG, but when is it futile and when should you go forward, any comments you want to summarize on that for everyone?

Dr. Gautam Kumar:
I think the general risk factors as to why a patient may not benefit from going to the lab early might be if they are extremely acidotic at time of presentation. I think arterial blood gas being obtained is an important part of the armamentarium. So if they're coming in with a pH of less than 7 or 7.1, the chances of getting a meaningful recovery out of that might be difficult if there's prolonged CPR with multiple shocks. If there significant comorbidities and age is one of these comorbidities, not necessarily the only comorbidity and these are all in by and large significant factors that affects what your outcome is going to be in coming out of the lab and those are the patients that maybe in approach of not going to the lab up front might be considered.

Dr. George Vetrovec:
Yeah, you didn't mention a lactate but looking at the things that would be really nice to know is like lactate and the CPO, if you had a right heart cath, these are all things that would really enhance how we approach that. I think those are important issues that we're beginning to grab a hold of these, but these are really impressive saves.

Dr. Bryan Kluck:
You're right about that George. In fact in years past and role have many years that have passed us by, I used to have a rule that said if the pH is less than seven, that patient's not leaving the hospital no matter what. I think that, number one, I've been proven wrong a couple of times. Number two, I think that the transition to making a common parlance be a lactate level and the calculations that are done is a really important transition and it takes not only us doing that but also our colleagues in the CICU and our house staff. So that becomes the coin of the realm, and I think that's very important.

Dr. George Vetrovec:
Gautam, any other thoughts or comments?

Dr. Gautam Kumar:
No, I'd like to again echo the importance of getting the lactate and the blood gas upfront in the ER as well, because this is going to be critical in the management of this patient.

Dr. George Vetrovec:
I think there's one thing that we really didn't mention up to this point and that is I think in your cases as I heard the presentations, you really didn't use a lot of inotropes. And one of the things that I think we've begun to focus a lot more on is, while we feel good because the pressure goes up many times with them, they're really negatively impacting the myocardium and the heart. One of the advantages of earlier support is that you're now reducing the dependence, hopefully getting them off the inotropes very quickly to minimize that adverse effect.

Dr. Bryan Kluck:
Sure.

Dr. George Vetrovec:
Any comment on these? I think you didn't have inotropes.

Dr. Bryan Kluck:
Absolutely, and I think that's exactly right. I think what happens when the LV dilates and the body responds to it, there's just this biochemical hurricane that really happens and I think if-

Dr. George Vetrovec:
Tsunami, that's the term.

Dr. Bryan Kluck:
Tsunami. Okay, I'll buy that. But I think that's right. I think what happens is that by placing the Impella in first, even before you do your intervention, you never get to the point of that storm and you never then have to undo the storm on the back end, and I think it's a learning process. We all have patients that dwell in the CICU and go through what's been tried-and-true protocol of presser after presser after presser at which point you're called to now add mechanical support to this. I think that's wrong thing, I think that really what we need to do is start early with mechanical support of an escalating variety and move from there.

Dr. George Vetrovec:
Well, I think this has been a great discussion, I've certainly learned a lot. If I can just summarize a little bit, I think what we learned is that, you were able to salvage two very sick patients. Maybe from a timing standpoint, we might've considered either earlier support, but the fact was these patients were supported, there were minimal inotropes and they left the hospital with good heart recovery. So I think very, very satisfying and gratifying approach. So thank you for sharing those cases. This is Dr. George Vetrovec, thank you for joining us.

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