Shift Toward Door-to-Support

October 8, 2019

Modern Approaches to AMI Cardiogenic Shock

Three clinicians discuss paradigm shifts in the treatment of AMI cardiogenic shock. In this webcast, Dr. George Vetrovec, Dr. Bryan Kluck, and Dr. Gautam Kumar provide case studies and insights illustrating when and how to use mechanical circulatory support, specifically Impella®, to optimize treatment in patients with cardiogenic shock.

Dr. Kluck presents an anterolateral MI case that helped precipitate changes in how cardiogenic shock was managed at his institution. After placing a balloon and stent across the LAD lesion in this patient, flow stopped. Noting elevated left ventricular end diastolic pressure (LVEDP), the team placed an Impella®. “At the time the case was done,” Dr. Kluck notes, “we really didn’t quite grasp the advantages of hemodynamic support prior to revascularization… the mechanical, the biochemical consequences of LVEDP elevation really have become clearer now.”

As a result, his program has implemented a cardiogenic shock treatment protocol that emphasizes the importance of using Swan-Ganz catheters to assess hemodynamics, using Impella prior to revascularization (door-to-support), weaning from inotropes (if used) as soon as possible, and having clinical support, such as that provided by the Abiomed Clinical Support Center (CSC) team. Dr. Kluck notes that clinical support issues are “very expertly interpreted” by the Abiomed CSC team, which he adds “are there at beck and call any time of the day or night.”

“We’ve also adopted the steps in this algorithm,” explains Dr. Kuman, “and we’ve found that our outcomes are actually better as well.” He describes a late-presenting anterior STEMI case with elevated LVEDP in which Impella CP® was placed immediately, prior to the stenting procedure. He describes placing a Swan-Ganz to obtain RA, RV, PA, and wedge pressures as well as calculating “more novel hemodynamic numbers”—cardiac output (CO), cardiac index (CI), cardiac power output (CPO), and pulmonary artery pulsatility index (PAPi)—post PCI. Dr. Kumar also discusses the significance of lactate in patient outcomes.

“I think that the adoption of the NCSI algorithm has really helped advance this, and this has generated a paradigm shift in the way that cardiogenic shock is treated,” states Dr. Kumar. Dr. Kluck adds, “I think we’re evolving. We’re going from door-to-balloon time to door-to-support time. And I think that will be borne out in our data.”

Dr. Vetrovec concludes noting that adopting and implementing cardiogenic shock protocols is a beneficial management strategy that can be part of what leading hospitals become known for and adoption of such strategies creates “a real opportunity to provide a service for the community.”

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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/

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