Mechanical Circulatory Support Devices in the Intensive Care Unit

EDITORS: Jacob Abraham, MD Joseph E Parrillo, MD, MCC

Rev 1 Feb 2021,Copyright 2021 All rights reserved This book is protected by copyright No part of this book or

Contents Preface i About the Editors ii Authors iv Introduction: Pathophysiology and Definitions 1 Mathew S Lopes, M

Intense interest in improving the historically poor prognosis of cardiogenic shock (CS) provided the impetus behind w

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,i

Dr Abraham is the section chief of Advanced Heart Failure for the Providence Heart Institute in Portland, Oregon He

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,ii

Dr Parrillo is the chairman of the Heart and Vascular Hospital at Hackensack University Medical Center and he holds

Authors

J Christian Cash, MD Assistant Professor of Clinical Surgery Division of Cardiothoracic Surgery Cardiovascular Thora

Matthew E Powers, MD Assistant Professor of Clinical Surgery Division of Cardiothoracic Surgery Cardiovascular Thora

Authors

Steven P Keller, MD, PhD Division of Pulmonary and Critical Care Medicine Brigham and Women s Hospital Harvard Medic

Introduction: Pathophysiology and Definitions

Pathophysiology of cardiogenic shock Cardiogenic shock is defined as cardiac dysfunction leading to end-organ malperf

Diagnosis and initial therapy A high index of clinical suspicion is required to promptly diagnose and treat patients

References Hajjar LA, Teboul J-L Mechanical circulatory support devices for cardiogenic shock: state of the art Cri

Duration of shock is associated with progressively worse outcomes and decreased survival which motivates intervention

Kolte D, Khera S, Aronow WS, et al Trends in incidence, management, and outcomes of cardiogenic shock complicating S

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management

Hemodynamic Assessment: Use of Right Heart Catheterization 25,Chapter 2 ,Overview of Mechanical Circulatory Support 7

Overview and Hemodynamics in Mechanical Circulatory Support,Part I

Introduction Cardiogenic shock is a highly morbid condition with mortality rates approaching 50% despite prompt diagn

Mathew S Lopes, MD Division of Cardiovascular Medicine Brigham and Women s Hospital Harvard Medical School Boston, M

Chapter 1 Overview of Mechanical Circulatory Suppor

Functional overview of MCS The primary therapeutic function of mechanical circulatory support is to restore systemic

Figure 1 Effects of Heart Failure on Cardiac State (A) Frank-Starling relationship and effect of heart failure on LV

Law of Laplace T Left ventricle (LV) wall stress P LV intraventricular pressure r Chamber radius h Wall thic

The Law of Laplace (see Box) states that wall stress varies directly with intracardiac pressure and chamber radius an

Figure 2 Effects of Increasing Intracardiac Pressure and Volume on Ventricular Wall Tension Cross-sections of heart

Cardiac muscle oxygen extraction is near maximal at rest 22 The highly efficient use of delivered oxygen demands that

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,1

CPP MAP LVEDP,Coronary Perfusion Pressure of the LV CPP coronary perfusion pressure MAP mean arterial pressu

Maintaining systemic blood flow while reducing intraventricular pressure is the key to maintaining global coronary pe

The physiology of heart failure provides insights into the operation of the ideal MCS device Such a device would fun

Figure 3 Hemodynamic Effects of IABP IABP inflates during diastole to increase diastolic systemic blood pressure and

Table 1 Commonly Used Percutaneous MCS Devices

LV support devices Intra-aortic balloon pump The IABP is a counterpulsatile balloon that sits within the descending t

Figure 4 Mechanism of Action of Impella Impella CP is placed across aortic valve Inlet in LV draws blood from ventr

Impella The Impella heart pump is a percutaneous catheter-mounted MCS device consisting of a microaxial flow pump tha

Figure 5 TandemHeart Withdrawal cannula across atrial septum withdraws oxygenated blood from left atrium Blood is r

The unique placement of the Impella within the LV provides the opportunity to leverage its positioning and functional

Figure 6 Peripheral Venoarterial ECMO Withdrawal cannula inserted into femoral vein and advanced to junction of infe

A further challenge of this form of circulatory support is limited understanding of the effects of retrograde perfusi

Physiologically, ECMO is similar to TandemHeart in that it increases afterload and has unpredictable effects on myoca

Figure 7 Impella RP and Protek Duo (A) Impella RP ejects blood directly into pulmonary artery bypassing failing RV

A small percentage of patients develop right ventricular failure because of isolated MCS to the LV Various metrics,

TandemHeart-Protek Duo The Protek Duo is a double lumen cannula designed to be inserted via the right internal jugula

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,2

Risks of MCS and patient selection Mechanical circulatory support can restore systemic perfusion and maintain end-org

References Hochman JS, Sleeper LA, Webb JG, et al Early revascularization and long-term survival in cardiogenic shoc

Summary Cardiogenic shock remains a highly morbid disease despite advances in mechanical circulatory support While t

Goodwill AG, Dick GM, Kiel AM, Tune JD Regulation of coronary blood flow Compr Physiol 2017;7(2):321-82 Boatwrigh

Esposito ML, Shah N, Dow S, et al Distinct effects of left or right atrial cannulation on left ventricular hemodynam

Korabathina R, Heffernan KS, Paruchuri V, et al The pulmonary artery pulsatility index identifies severe right ventr

Introduction Since the ESCAPE trial in 2005, right heart catheterization and hemodynamic monitoring have been controv

Craig S Smith, MD Assistant Professor of Medicine, University of Massachusetts Medical Director, Cardiac Intensive C

Chapter 2 Hemodynamic Assessment: Use of Right Heart Catheterizatio

The evidence for PAC use today While still a Class I indication in professional guidelines for use in decompensated h

Twist to lock unlock I Locked O Open,Figure 1 Proximal and Distal TwistLock Cath-Gard Lockable guards secure the

PAC insertion and maintenance Pulmonary artery catheter insertion can be performed in the OR, cardiac catheterization

The following should be available during the insertion and placement of PACs: A code cart, as insertion can cause ven

C,B,A,Figure 2 Determining Proper Damping A Normal 1-2 bounces 1 block between bounces 2nd bounce should be 1 3

PAC advancement 1 Prior to insertion of the PAC, test balloon inflation outside the body 2 When past the sheath,

Figure 3 Advancing the PAC RA typically reached at 20 cm Transition to RV noted by rise in systolic pressure Transit

Pulmonary artery catheter setup and insertion videos are available online For example: https: youtu be dT_ul3nvB3o

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,3

If you encounter difficulty getting the PAC past the tricuspid valve, place the patient s head down to aid the transi

Complications In addition to general complications of central venous access (eg, hemorrhage, pneumothorax, infection)

Measurement parameters Invasive hemodynamic assessment (PAC) provides an important adjunct in the diagnosis and conti

Table 2 Hemodynamic Parameters and Formulas for Assessing RV Function (adapted from Kapur et al 12) AMI acute myoc

Post-insertion and removal Like all central access, PACs should be left in only for as long as indicated Check the s

References Wiener RS, Welch HG Trends in the use of the pulmonary artery catheter in the United States, 1993-2004 J

$Aschauer S, Kammerlander AA, Zotter-Tufaro C, et al The right heart in heart failure with preserved ejection fractio$

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management

Impella Removal and Closure 86,Chapter 10 ,Weaning of Impella 81 ,Chapter 9 ,Blood Compatibility Hemolysis 76 ,Chapte

Mechanical Circulatory Support with Impella Devices: Insertion, Management, and Removal,Part II

Introduction Percutaneous mechanical circulatory support (MCS) devices have continued to evolve since the advent of t

For patients in which large bore access for MCS is planned, the iliofemoral anatomy is often known If the anatomy is

Table 1 Arterial Cannula Size and Minimum Vessel Diameter of Common MCS Devices

Table 2 Clinical Factors Associated with Vascular Complications

Figure 1 Transesophageal Echo of Ascending Aorta and Arch

Right ventricle ,Left atrium,Left ventricle ,Aorta

Table 3 Imaging Modalities for Large bore Vascular Access (adapted from Cohen et al 16)

,Due to hemodynamic instability or inability to safely transport the patient (eg, preexisting ECMO with need for retr

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,4

,Femoral access techniques While bedside cannulation and access is feasible, fluoroscopic-based placement is recommen

Figure 3 Single Access for High-risk PCI (SHiP) Techniqu

,Perfusion strategies for distal ischemia due to MCS devices Registry data from MCS trials have shown vascular compli

Internal contralateral circuit Use this technique for patients with pre-existing occlusive disease or iatrogenic tota

Figure 7 Contralateral Distal Retrograde Circuit

External ipsilateral circuit May be placed at bedside in ICU with sterile technique and ultrasound Confirm adequate

,Transport considerations The safe transport of patients with MCS devices is not a trivial consideration given the an

Best practices for MCS removal Remove large bore arterial access for MCS devices in a procedural room or with fluoros

Figure 8 Temporary Cross-over Balloon Tamponade Dry Closure Techniqu

Suture-based closure devices Perclose ProGlide 6 Fr and Prostar XL Percutaneous Vascular Surgical System 10 Fr (Abb

Table 3 Registry Data of Vascular Complications with Impella and TandemHeart Devices (adapted from Patel et al 5)

Complications It is not surprising that large caliber arterial access for MCS devices translates into higher rates of

Massive Transfusion Checklist Monitoring 2 large bore IVs (14-16 gauge); if central line, use multiport trauma line f

Transfusion Centers performing any large bore access should be prepared to resuscitate patients due to massive blood

References Kaki A, Blank N, Alraies MC, et al Access and closure management of large bore femoral arterial access J

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,5

Summary The use of MCS devices continues to revolutionize the care for patients with cardiogenic shock The routine a

Danial P, Hajage D, Nguyen L, et al Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity sco

CHAPTER

4

Introduction The field of interventional cardiology has throughout its history evolved to optimize catheter-based the

Timothy D Smith, MD Interventional Cardiovascular and Critical Care Medicine Director, Farmer Family Cardiovascular I

Chapter 4 Axillary Artery Access and Managemen

3 Use an additional access point to image the axillary artery I prefer the ipsilateral radial artery or in cases w

5 Use a micropuncture needle to access the second portion of the axillary artery using fluoroscopic guidance and ul

Figure 3 Balloon Inflated for Dry Closure While Removing the Impella Sheat

4 Completely remove the Impella sheath over the 0 035 wire already in place and complete the pre-close technique b

Figure 4 Extravasation and Covered Stent Placement,Balloon to seal arteriotomy,Covered stent placement,Axillary arte

Summary Axillary artery access offers an alternative to large-bore femoral access Despite what is typically a smalle

References Tayal R, Iftikhar H, LeSar B, et al CT angiography analysis of axillary artery diameter versus common fem

CHAPTER

5

Introduction The Impella heart pump is a percutaneous ventricular assist device (pVAD) commonly used to support pati

Kanika P Mody, MD Medical Director, VAD Program Heart and Vascular Hospital Hackensack University Medical Center Hac

Chapter 5 Percutaneous Ventricular Assist Device Console Managemen

Positioning When the Impella is correctly positioned, both the placement signal and motor current signal should be pu

Purge Flow and Purge Pressure ,Impella flow ,Motor current waveform ,LV placement signal waveform ,Ao placement signa

Suction A suction alarm may indicate decreased blood flow through the Impella pump The clinical team should troubles

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,6

If the LV and aortic peaks on the console are not overlapping and the LV tracing reveals significantly negative diast

Figure 2 Diastolic and Continuous Suction as Displayed for Impella with SmartAssist

References Impella CP with SmartAssist For Use During Cardiogenic Shock and High-Risk PCI Instructions for Use and

Summary It is important to understand the parameters displayed on the Impella console in order to ensure proper Impel

CHAPTER

6

Introduction A patient is admitted to the cardiac intensive care unit (CICU) and a team is assembled to review the ca

John Adam Reich, MD Director of Cardiovascular Critical Care ECMO Medical Director Tufts Medical Center Tufts Unive

$Case study A 35-year-old male with nonischemic cardiomyopathy, ejection fraction (EF) 10%, loses consciousness while$

The cardiac care unit (CCU) of the past was a post procedural suite for care of post STEMI patients who received inte

Figure 2 Outcomes Before and After Adding Intensivist to Multidisciplinary CCU Team (adapted from Fanari et al , 201

Figure 3 Significant Reductions in CICU and In-hospital Mortality Associated with Cardiac Intensivist-directed Care

Physical therapists, occupational therapists, and speech-language pathologists Gone are the days when patients in the

References Fanari Z, Barekatain A, Kerzner R, et al Impact of a multidisciplinary team approach including an intensi

CHAPTER

7

Introduction Patients treated with mechanical circulatory support (MCS) are at high risk for both thrombosis and ble

Satya Shreenivas, MD The Christ Hospital Heart and Vascular Center The Lindner Research Center Cincinnati, OH satya s

Figure 1 Sheath Thrombosis with Failure to Remove Peel-away Sheath Large thrombus removed from the Impella peel-awa

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,7

Risk of thrombosis and bleeding with MCS Patients treated with MCS devices, such as extracorporeal membrane oxygenati

Figure 2 Importance of Impella Purge Flow (Courtesy of Abiomed) The retrograde flow of a continuous purge infusion c

Elevation in lactate dehydrogenase (LDH) and plasma free hemoglobin can suggest increased hemolysis, which can have m

Table 1 Heparin Dosing Recommendations for Impella

Bleeding Patients supported with MCS are also at risk for bleeding at the site of device insertion (usually related t

Table 2 Monitoring Anticoagulation (adapted from SCAI recommendations)9

Figure 3 Heparin Rate Calculator (Courtesy of Abiomed) Monitoring of anticoagulation should include activated clotti

Table 3 Alternative Anticoagulation Dosing Recommendations

There are case series of patients successfully treated with both argatroban and bivalirudin in ECMO11, 12 as well as

References Hassett CE, Cho SM, Hasan S, et al Ischemic stroke and intracranial hemorrhages during Impella cardiac su

CHAPTER

8

Introduction All axial and centrifugal mechanical circulatory support devices (MCSD) cause mechanical trauma to blood

Jacob Abraham, MD Medical Director, Advanced HF, MCS, and Heart Transplant Providence Heart Institute Portland, OR Ja

The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) defines minor hemolysis and major

Table 2 Reported Incidence of Hemolysis in Cardiogenic Shock for MCSD AMICS acute myocardial infarction complica

Management recommendations For all MCSD, serial monitoring of LDH, PFHb, and haptoglobin is recommended to identify a

Figure 1 Echo Images of Impella Positioning Optimal Impella position Impella inlet positioned in papillary muscle (t

Optimize volume status, using pulmonary artery catheter guidance when possible, to avoid hemolysis from inadequate LV

References Olia SE, Maul TM, Antaki JF, Kameneva MV Mechanical blood trauma in assisted circulation: sublethal RBC d

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,8

CHAPTER

9

Introduction Throughout the management of a patient with an Impella device in place, it is important to continually

Waqas Ghumman, MD Affiliated Clinical Assistant Professor of Medicine, University of Miami Director, Mechanical Circu

Initiating weaning While there is no established minimal duration of support, many sites advocate for an Impella to r

Weaning strategy A conscientious weaning strategy requires patience and diligence Ideally, as the mechanical circula

Cardiogenic risk predictors for increased 30-day mortality Lactate 3 mmol L at 24 hours Pressor duration from diagn

References Vahdatpour C, Collins D, Goldberg S Cardiogenic shock J Am Heart Assoc 2019;8(8):e011991 doi:10 1161 J

Conclusion Weaning from a mechanical circulatory support device, such as Impella, can be a very challenging aspect of

CHAPTER

10

Introduction The removal of the Impella heart pump is critical to the overall success of the procedure as well as th

Figure 1 Balloon Inflated for Dry Closure Hemostatic Contro

Impella CP and Impella 2 5 removal Removal techniques for the Impella CP and Impella 2 5 are essentially identical

Arteriotomy closure Depending on individual preference and device availability, dry field closure of the arteriotomy

Figure 2 Manual Compression with FemoSto

Pre-close technique with Perclose If 1 or 2 Perclose ProGlide vascular closure devices were placed prior to the inser

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,9

Post close technique Although the pre-close technique is frequently utilized, unfortunately, there will be circumstan

Removal of the Impella RP The Impella RP has a 22 Fr pump motor and requires a 23 Fr sheath for insertion The devic

Removal of the Impella 5 0 and Impella 5 5 The Impella 5 0 and Impella 5 5 require a 23 Fr sheath for insertion Al

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management

ECpella: Physiological Basis and Clinical Management of Dual Mechanical Circulatory Support with ECMO and Impella CP

Mechanical Circulatory Support: Other Devices,Part III

CHAPTER

11

Introduction The intra-aortic balloon pump (IABP) is a cardiac mechanical circulatory support (MCS) device that works

Arvind Bhimaraj MD, MPH, FACC, FHFSA Interim Chief, Division of Heart Failure Medical Director, Advanced Heart Failur

Physiology and anatomy of the pump The IABP is a catheter-based device with a 22-27 5 cm long balloon with a 34-55 cc

Figure 1 Physiologic Impact of IABP Timing

The IABP appears to augment cardiac output by 0 5 to 1 L min and can be set to assist every beat, every other beat, o

It is possible that a device that depends on native cardiac contractility might not be sufficient in a setting like S

Figure 2 Technique for IABP Removal A Pull IABP until deflated balloon lodges in introducer sheath B Remove IABP

IABP patient management Key IABP patient management tips include the following: When the IABP is placed in the femora

Percutaneous axillary IABP: a special mention The option to place an IABP through the upper extremity arterial circul

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,10

$Longer maintenance can also lead to a need for IABP exchange due to fracture of the helium port in the catheter (as s$

References Parissis H, Graham V, Lampridis S, et al IABP: history-evolution-pathophysiology-indications: what we nee

CHAPTER

12

Joseph E Parrillo, MD, MCCM Justice Marie L Garibaldi Endowed Chair, Chairman Heart and Vascular Hospital Hackensac

Traditional ECMO Nomenclature First letter Source of deoxygenated blood from body to pump Second third letter De

Chapter 12 ECMO: Configurations and Managemen

Figure 1 Typical ECMO Cannulation Configurations (adapted from Murphy et al 18) Cannulation configurations and commo

ECMO circuit components ECMO was developed as a modified cardiopulmonary bypass circuit A centrifugal pump removes b

Figure 2 Single Cannula V-V ECMO Access obtained through the right internal jugular vein Cannula has several extern

Alternative configuration In addition to the common configurations, a newer setup for V-V ECMO has been designed, sim

Patient selection ECMO is a resource-intensive strategy, which like other advanced medical treatment tools and strate

Table 1 Common V-A and V-V ECMO Indications

$Table 2 Parameters Indicating Refractory Hypoxic and Hypercarbic Respiratory Failure and Consideration for V-V ECMO$

Relative contraindications Although some authors site specific absolute contraindications for ECMO, there is no conse

Table 3 General Management Principles for ECMO Circuits2,11 PaCO2 partial pressure of carbon dioxide; SaO2 oxy

A team of trained clinicians and ECMO specialists should carefully coordinate management of ECMO cases within an inst

Accomplishing physiologic rest to allow recovery is an important mechanism by which ECMO is thought to benefit patien

Complications International organizations such as ELSO track ECMO cases and monitor complication rates in participati

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,11

References Marasco SF, Lukas G, McDonald M, et al Review of ECMO (extra corporeal membrane oxygenation) support in c

Combes A, Hajage D, Capellier G, et al Extracorporeal membrane oxygenation for severe acute respiratory distress syn

CHAPTER

13

Introduction ECpella denotes concurrent use of both extracorporeal membrane oxygenation (ECMO) and an Impella hear

Figure 1 Peripheral Veno-Arterial (V-A) ECMO (adapted from Murphy et al 32)

ECMO support profoundly alters physiological blood flow and effectively decouples the arterial system from the left v

Figure 2 ECMO Support and Watershed Region

Methods to either directly or indirectly augment LV emptying (see Box) are termed venting and are initiated in an e

,The Impella heart pump provides multiple potential advantages over other LV venting strategies including the followi

Figure 4 Perfusion Provided by ECpella Support

,Compared with ECMO-only support, during which all antegrade perfusion derives from residual function of the failing

,Patient monitoring The major goals of patient monitoring are to ensure adequate end-organ perfusion and oxygenation

,3 Maintain goal MAPs of 65 to 80 mmHg Initiate and titrate vasopressor or vasodilator therapy as needed to mainta

,Weaning and de-escalation of ECpella support Weaning of MCS is an ongoing area of investigation requiring further ex

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,12

,The optimal duration of the ramp trial prior to determination of decannulation is unknown but typically on the order

,Ventilator management Patients with profound shock requiring ECpella support are frequently intubated and maintained

References Vallabhajosyula S, O Horo JC, Antharam P, et al Venoarterial extracorporeal membrane oxygenation with con

Chang BY, Keller SP, Bhavsar SS, et al Mechanical circulatory support device-heart hysteretic interaction can predic

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management

Mechanical Cardiac Support Use in COVID-19 169,Chapter 19 ,Non-Cardiac Critical Illness Management 156 ,Chapter 18 ,N

Mechanical Circulatory Support: General Management Issues,Part IV

CHAPTER

14

Introduction Interhospital transfer of critically ill patients is a safe and effective method of matching patients wi

Brian Porvin, DO Vice Chairman of Internal Medicine Honor Health Deer Valley Medical Center Phoenix, AZ b porvin pulm

Chapter 14 Patient Transfer Consideration

,Hub and spoke model The hub and spoke model describes a network of hospitals that care for patients with a diverse

Figure 2 Lactate and CPO as Predictors of Survival at 12 and 24 Hours (adapted from Basir et al 2) ,Figure 1 Propo

,Hospital capabilities When considering whether to transfer a patient, it is important to understand hospital capabil

Table 2 Capability Considerations for Various Care Options

,Care options There may be several care options to consider for a patient with AMI complicated by cardiogenic shock

Table 3 Key Patient Transfer Considerations

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,13

,Modes of transfer Modes for transferring patients from one hospital to another include: Ground transport Fixed wing

Transfer considerations specific to Impella Specific pre-transfer considerations for patients supported with an Imp

,Summary Many hospitals utilize a hub and spoke model in which critically ill patients, such as those with cardiogeni

References van Diepen S, Katz JN, Albert NM, et al Contemporary management of cardiogenic shock: A scientific statem

CHAPTER

15

Introduction Despite advances in the management of acute coronary syndromes, cardiogenic shock complicating acute myo

Greg Marco, MD, FCCP Medical Director for Cardiothoracic Critical Care Frederik Meijer Heart & Vascular Institute 100

Chapter 15 Escalation of Care in Cardiogenic Shoc

,Early recognition of AMICS When a patient presents with acute myocardial infarction, timely recognition and therapeu

,Hemodynamic assessment In patients who develop hypotension or need for vasopressors during or following PCI, RHC is

Figure 3 Inova Cardiogenic Shock Management Algorithm ,Figure 2 Prompts for considering escalation of support from

In-hospital Survival Post Impella PCI Based on CPO and Inotrope Use4

Predictors of In-hospital Survival 12-24 Hours Postprocedure Based on Lactate and CPO4

References Miller L Cardiogenic shock in acute myocardial infarction: the era of mechanical support J Am Coll Cardi

,Earlier chapters have emphasized the value of a shock team, use of RHC for hemodynamic-tailored therapy, and ability

CHAPTER

16

Introduction Today there is a growing need to integrate palliative care (PC) decision making into a team-based treatm

Charles Hunley, MD Critical Care Director Orlando Regional Medical Center Orlando Health 86 W Underwood Suite 101 Orl

Challenges to palliative care with acute AMI in cardiogenic shock include: Delayed recognition Waxing and waning cli

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,14

,In one study, heart failure (HF) providers were interviewed to assess knowledge, attitudes, and perceptions about PC

$,,With advanced HF patients the predictors of all-cause mortality are: Reduced ejection fraction Low systolic blood p$

The American Heart Association outlined triggers and indicators of PC readiness derived from advanced heart failure (

Figure 1. SCAI Cardiogenic Shock Stage Descriptions14

Table 1 Indicators of Readiness for Palliative Care Derived from Advanced Heart Failure (adapted from American Heart

,Although treatment modalities and clinical prognostic tools have improved for cardiogenic shock, variability in trea

References von Schwarz ER, He M, Bharadwaj P Palliative care issues for patient with heart failure JAMA Netw Open

CHAPTER

17

Introduction While cardiogenic shock due to acute coronary syndrome (ACS) is the primary indication for mechanical ci

Chapter 17 Non-Acute Coronary Syndrome Cardiogenic Shoc

Life-threatening conditions, other than ACS cardiogenic shock, present in approximately 20% of patients who receive

Left ventricular support devices have advantages and limitations, which are detailed in prior chapters With regard t

Figure 1 Pressure-Volume Loops Reveal Cardiac Effects of MCS Devices A Activation of intra-aortic balloon pump (IAB

,Severe heart failure in the setting of non-ischemic cardiomyopathy Appropriately deployed MCS can mitigate the press

,Accumulating evidence suggests that MCS may provide a bridge to recovery for patients with fulminant myocarditis,

Table 2 Mechanical Circulatory Support Devices for High-risk Pulmonary Embolism (adapted from Elder et al , Interv C

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,15

,Implementation of MCS in acute PE is highly time sensitive as patients with massive or submassive PE can decompensat

Table 3 Anatomic Variations in Patients with Stress Cardiomyopathies16 (adapted from Medina de Chazal et al, J Am Co

,Takotsubo and other stress-induced cardiomyopathies Takotsubo cardiomyopathy (aka apical ballooning syndrome or b

,Treatment for stress-induced cardiomyopathy is mainly supportive, although recent efforts have focused on identifyin

Relatively common measurements may play a role in triaging patients in cardiogenic shock and quantifying early effec

References Hritani A, Allaqaband S, Jan MF Cardiogenic shock In: Akin I, ed Interventional Cardiology IntechOpen;

Sergi C, Shen F, Lim DW, et al Cardiovascular dysfunction in sepsis at the dawn of emerging mediators Biomed Pharma

CHAPTER

18

Introduction The cardiac intensive care unit (CICU) is not a coronary care unit (CCU) Following percutaneous coronar

Douglas M Fetterman, MD Medical Director of Critical Care Services Anesthesiology and Critical Care Medicine St Jose

Chapter 18 Non-Cardiac Critical Illness Managemen

Figure 1 Levels of Care for Cardiac Shock (adapted from Rab et al 2) ,Managing modern CICU patients To manage the mo

Assess, prevent, and manage pain Assess pain with Critical Care Pain Observation Tool (CPOT) or Behavioral Pain Sca

Figure 2 Society of Critical Care Medicine s A-F Bundle of Care (adapted from Hayhurst et al 3)

,The use of the A-F bundle has been shown to reduce:4,5,6 ICU length of stay Ventilator days Ventilator associated ev

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,16

,The SCCM published sedation guidelines in 2018 8 Recommendations include: Propofol or dexmedetomidine are recommende

,When choosing between NIPPV and MV, it s important to understand the risks and the benefits of each method of suppor

,Interventional cardiologists often receive patients who were given CPR prior to arrival and may have aspirated oral

Table 1 SIRS Criteria (adapted from Alsulaiman 2017)13

Unfortunately, most patients with acute myocardial infarction and cardiogenic shock also present with similar physiol

Fluid management in patients with heart failure and end stage renal disease is an often-contested area of sepsis mana

Table 2 Surviving Sepsis Campaign: Hour-1 Bundle (from Surviving Sepsis Campaign)19

,Neurological injury after cardiac arrest: prognostication and mitigation Cardiac arrest remains a major health issue

Table 3 Sample Prognostication Algorithm for Comatose Patients Following Cardiac Arrest (adapted from Sandroni et al

,Neurological prognostication begins almost immediately in the post-arrest patient once spontaneous circulation has b

References Morrow DA, Fang JC, Fintel DJ, et al Evolution of critical care cardiology: transformation of the cardiov

,Summary Today, patients in the CICU tend to be complex patients with multisystem organ failure Delirium, respirator

Liu VX, Fielding-Singh V, Greene JD, et al The timing of early antibiotics and hospital mortality in sepsis Am J Re

CHAPTER

19

Introduction The COVID-19 global pandemic has, as of mid-September 2020, affected more than 28 million patients world

Vittorio Pazzanese, MD Intensive Cardiac Care Unit San Raffaele Scientific Institute Milan, Italy vittorio pazzanese

Chapter 19 Mechanical Cardiac Support Use in COVID-1

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,17

Figure 1 COVID-19 Symptoms ,COVID-19 disease background Coronavirus disease 2019 (COVID-19) is caused by severe acut

Figure 2 Cardiovascular Consequences of COVID-19 Infection ,Cardiovascular consequences of SARS-CoV-2 The prevalence

Figure 3 COVID-19 and Direct Vascular Injury ,Acute coronary syndrome As with other viral infectious diseases, COVID

Acute respiratory illness and shock Acute respiratory illness is the main presentation of COVID-19 which may lead to

Figure 5 Mechanical Pulmonary and or Circulatory Support and COVID-19 ,Echocardiography should be performed in patie

,Mechanical pulmonary and or cardiac support and COVID-19 In management of acute pulmonary failure related to COVID-1

Figure 7 EuroELSO Registry Report of ECMO in 1531 Patients with COVID-19 (September 14, 2020) ,Current unpublished

,When considering whether to implement ECMO, consider the following: Restricting use to patients with isolated single

Figure 8 Mechanical Circulatory Support for Patients with COVID-19 ,Mechanical circulatory support (MCS) approaches,

,Right ventricle mechanical support A recent study revealed right ventricular (RV) dilation, diminished RV function,

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,18

,Patients with severe COVID-19 might have a cytokine storm syndrome that manifests as hemophagocytic lymphohistiocyto

,Heart transplantation during COVID-19 pandemic Currently data show a dramatic reduction (up to 60%) in the number of

References Dong E, Du H, Gardner L An interactive web-based dashboard to track COVID-19 in real time Lancet Infect

Karmpaliotis D, Kirtane AJ, Ruisi CP, et al Diagnostic and prognostic utility of brain natriuretic peptide in subjec

Pieri M, Agracheva N, Bonaveglio E, et al Bivalirudin versus heparin as an anticoagulant during extracorporeal membr

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management

Regionalization and Protocolization of the Treatment of Cardiogenic Shock and Need for Mechanical Circulatory Support

Mechanical Circulatory Support and Systems of Care,Part V

CHAPTER

20

Introduction Cardiogenic shock (CS) is one of the primary indications for admission to the cardiac intensive care uni

Shashank S Sinha, MD, MSc, FACC Assistant Professor of Internal Medicine Virginia Commonwealth University School of

Chapter 20 Cardiogenic Shock Systems of Car

Table 1 Characteristics of Cardiogenic Shock Centers (adapted from van Diepen et al 4)

,Cardiogenic shock center characteristics In 2017, an American Heart Association (AHA) scientific statement proposed

CICU cardiac intensive care unit; CRRT continuous renal replacement therapy; ECMO extracorporeal membrane oxygenatio

,High-volume cardiovascular centers are designated as CS receiving ( hub ) centers and receive patients from lower ac

,Figure 1 Three-Tiered Structure for Cardiac Shock Care Centers (adapted from Rab et al 5) In this proposed framewor

Figure 2 Proposed CICU Algorithm for Management of Cardiogenic Shock (adapted from Tehrani et al 8)

Mechanical Circulatory Support Devices in the Intensive Care Unit: Post-Implant Care and Management,19

Figure 3 Shock Care Pathway Algorithm (adapted from Tehrani et al 8),The team of specialists should consider and dis

References Bohula EA, Katz JN, van Diepen S, et al Demographics, care patterns, and outcomes of patients admitted to

,Collaborative cardiologist-intensivist co-management model Kapoor and colleagues conducted a pre-and-post study of 3

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