Chapters Transcript Video Cardiogenic Shock: Protocols, Teams, Centers, and Networks Hosted by Dr. Sameer Khandhar and Dr. Ben Vaccaro Topic: “Cardiogenic Shock Protocols, Teams, Centers, and Networks.” And Samir just let me know when. Yeah, I was just about the same. Ben. Do you wanna go ahead and get started? Sure. Ok. Hi, everyone. Thanks for coming. Um I'm very excited to introduce uh Alex Trussell for grand grand rounds this morning. Um He graduated from the University of Southern California Medical School uh and then moved to complete his internship and residency at Walter Reed Army Medical Center. He went to Brown for cardiology and Interventional Fellowships. Um He also has a decade of service with the United States Army Intelligence, Infantry and Special Operation Units uh including um significant service abroad. Um And he's currently part of uh uh probably one of the most comprehensive cardiogenic shock programs. Uh He's been the leadership um in this multi multidisciplinary cardiogenic shock program at a Nova. Um And he's uh internationally respected uh subject matter expert on cardiogenic shock. Um And I'm very excited uh for him to be here today, especially as we um work to rele our shock program here. Um And he has uh I've heard him speak before and has absolutely wonderful insight on the matter. Um And um and with that, uh Alex. Thanks for being here. Awesome. Uh Ben, uh and everybody, Samir and everybody from U Penn. Thanks so much for uh having me. The, the only problem with a nice introduction is that it can only go downhill, uh from, from there. But, and, and ironically, I'm speaking to you from a, uh, a hotel room in, in, in Philly because I'm chaperoning a uh uh a middle school field trip. Uh but, uh, but I'm glad I could be with you guys virtually. I'm gonna go to my first slide. Um So again, I'm gonna talk about cardiogenic shock, uh really focusing in on um something that I'm passionate about and I put a lot of effort into um development of protocols, building teams growing centers and then establishing uh networks. I think the entire field of cardiogenic shock would be too much to cover. But that's gonna be my, you know, primary focus. Here are my um here are my uh you know, financial and other uh disclosures. So uh little very, very, very briefly what a shock and then really pivot into, you know, some of the background and why I think protocols and teams are important, how we can pivot to the centers and networks, what I think all of us can do and then what the um you know, no knowns, known, unknowns and unknown unknowns are. So, what a shock, there's a lot of uh definitions out there. I, I think, you know, one of the easiest ways to simplify it is just end organ dysfunction due to insufficient cardiac output. And um I think discriminating between acute or acute on chronic and whether it's, you know, uh uni or biventricular. And, and obviously, there's a lot more nuance and a lot of folks, particularly in the heart failure community have really delved into some of the nitty gritty details. But I think this is a nice construct for just kind of starting out thinking about it. Um I'm an interventional cardiologist, so I'm going to uh selfishly start with a Q to my cardiogenic shock. Although um I think as all of us know, heart failure, cardiogenic shock predominates now. And certainly in um our institution is really pivoted percentage wise from ami to uh heart failure as the predominant um uh a phenotype. But I think looking at ami shock, you know, when I came to um my private private group, Virginia Hart and um the Iova Health System in two thou end of 2015. Um I think the situation was the same all around the country, persistently high mortality. Um If you look at the uh you know, people talk about killip class heart failure, it's really interesting to read the 1967 killip paper. And what's fascinating is you see a 50% mortality at 10 hours and you see, you know, uh 90% shock mortality overall. Um there was a decrease in the nineties with um a movement towards early revascularization versus immediate medical therapy for shock. Um But otherwise, again, kind of stagnant if you look at, um you know, some of the data from whole whole grail bloom pump um uh versus impala, you know, one of the big takeaways was not the device takeaway, but really that mortality was still very high across the board. Uh Thankfully, we've moved beyond a state of the art uh care. This is the uh Cook County Hospital Intern manual from 1945 bed rest oxygen, morphine blankets, caffeine loose stools and PHENobarbital for the management of a coronary occlusion. Uh But I think this still highlights the importance of uh you know, protocols and systems of care. But I think it also demonstrates that uh these need to evolve significantly over time. Um I've always really liked this slide from uh Naveen Kapoor that I first saw published like 2015, 2016 because I think, you know, a a lot of us. And certainly before when you thought about, hey, how do we treat acute myocardial infarction with or without cardiogenic shock. It was coronary perfusion. You know, I'm a hammer, here's a nail and that's that. And, and this really, you know, to me highlighted the importance of ventricular support, circuitry support that we also we want to maintain vital noncardiac organ perfusion, reduced myocardial oxygen demand. So, you know, ventricular protection and you know, increase coronary flow. And then how this not just, you know, interrupt this systemic inflammatory response system response, but how this all interconnects and how maybe by doing some of the first three things together, you can um help improve. The last I mentioned briefly, some of the uh shift uh and demographically that a lot of centers are seeing. And certainly ours is no exception from um ami to acute decompensated heart failure, cardiogenic shock. And I think there's been some nice papers out there. And although some of the um treatment strategies are similar, there are a lot of key differences. And I think one of the biggest things that I think about between AMI and acute de compensated heart failure is that patients are walking in the door with different baseline hemo metabolic states and um different preadmission, uh physiologic compensation. So, you know, I always tell house staff, the um you know, the the heart failure patient may be, you know, walk in the track uh for an hour with a, you know, outpatient ambulatory shot cardiac index of 1.8. When we're thinking about therapies for that person, we don't need to provide a level of support to get them back to normal versus somebody who, you know, decompensates immediately with no pre-existing compensatory mechanisms. Likewise, what is the trajectory is this person? Are we aiming for recovery um or are we looking for some advanced heart failure therapies or heart re replacement therapies? And I I've certainly learned a lot from my uh heart failure and surgical colleagues being part of, um, you know, shock team, which is another really important side benefit, uh Swan Ganz. So I actually started off in general surgery and I remember, um it by, you know, the first month, if you weren't signed off on Swan Gans, you know, by yourself solo as an intern, uh having done at least five in your first month, you were sort of a drag on this on the system. And then there entered this, you know, long period of, of darkness where the Swan Ganz was determined to be um useless. And so it's really nice to see this resurgence and a refocus on physiology. A lot of that driven by heart fire, folks, frankly, a lot of it driven by, you know, structural heart. Um and, and again, it's always an interesting debate talking about Swan Games because it is not a treatment. And I think we all know that, but to me, it provides actionable data. And if you, if you get good data and it is actionable data and you use that data to guide downstream decision making, which does require some requisite knowledge of human dynamics and phenotyping um in that way, it can improve outcomes. And I think there's been, you know, a, a series of um mostly, you know, registry paper, a lot of it from the Shock Working group C three TN um that have demonstrated value. And if you look back even to the original literature, if you parse out the heart failure and shock population even then, um I think, you know, there was benefit demonstrated versus the escape trial would sort of said, you know, if you put in uh um you know, a P A catheter in every single person in the hospital, is that gonna change outcome? We have a, a lot of uh devices at our disposal. Um Now, which is great. Uh There is no perfect device. And uh so if somebody says there's a perfect device, I I would find that to be um not true. Uh but we do have a lot of options and sometimes it's plug and play options. And so again, some of this is thinking about, are you looking for circulatory support? Are you looking for ventricular support? Are you looking for oxygenation support? Do you need? Right, ventricular support, left ventricular support and by ventricular support, do you have um vascular access considerations? Is this um are you looking for short term therapies? Are you looking for midterm therapies? Are you looking for long term therapies? Uh What are um patient specific, unique uh risks and uh complication hazards and then also within your institution? What is your skill set experience? And is that something you can get better as a team? Is it something that's fixed? Um The device usage is that can look different by institutions and I think this really has to be tailored both to the, you know, patient um and to the uh institution and to the the team. But I think what also highlights is, is all these things get more and more complex. It really just um highlights the importance of having, you know, not just a cardiac surgeon or not just an intensivist or not just an interventional cardiologist or not just a heart failure specialist um involved in this decision making, but really leveraging the expertise of everyone. I like this slide because it's just a very simple cartoon. So I think particularly, you know, and people trying to wrap their head around what do different devices do. Um you know, I always again tell trainees um uh that, you know, that if we, if, if your attendings look really, really smart, it's just because they um were able to simplify things and they, you know, the smartest people just kind of keep things simple. And um I, you know, I remember uh when I was in the army, so every single uh military manual is written to a intentionally to a public school, eighth grade, uh uh reading and writing level. And so I think that's when, you know, that's the way we should all talk to patients, talk to colleagues, particularly from other specialties. And this diagram is nice because it really just shows blood is moved from where to where does it go from, you know, a, a blue to red. Is it that have oxygen not oxygen? Do you provide oxygenation or do you not provide oxygenation? And I think this is a nice framework processing, you know, uh what devices provide circulatory support and which ventricle ventricle support and then get oxygenation support a lot of stuff in the news about clinical trials appropriately. So, um this is I I love this slide from hold or tle um because he always highlights uh and I think this was demonstrated by the, by the danger shock trial. Maybe we, you know, if there's questions about that later, but populations of interest. So um depending on what group you decide to study and your inclusion or exclusion criteria, you could have people that will survive with or without a therapeutic intervention. So you say great my, you know, intervention, whatever it is works because they survived, but they all would have survived anyhow, you could have another cohort that they're gonna die no matter what. And then you say my therapeutic intervention does not work because they died. And, and I think this is the sweet spot on which I have immense respect for people um that develop and run uh clinical trials and particularly in the cardiogenic shock space where you have a lot of issues where things have to move very quickly, you have informed consis um consent issues. But um I think this has driven certainly United States probably, you know what I I first heard AJ K uh from Columbia say you simultaneous overuse and under use of mechanical circulatory support, both for shock and for, you know, high risk um uh intervention. I think there's a lot of benefit to be had from a multi center registries. So we have um the, the I know a shock registry which we stood up in 2017. I think that's, you know, important. Um But again, it's still not randomized controlled data. Uh That being said, I think, you know, a lot of kudos, the cardiac critical care trials, network, um team cardiogenic shock working group. Um Now, the A H A Cardiogenic Shock registry, um there's um you know, a Japanese um registry, the National Cardiogenic Shock Initiative. Um Some colleagues in the UK are looking to roll out um which would be very enticing within a national health uh network, a comprehensive registry. So I really hope that um uh pans out and then some pane registry data. So I think there's complementary role for um for both registry and randomized control trials, both to show prac practice patterns. Uh what systems of care may or may not work and maybe uh you know, unearth some um potential pitfalls that being said there's really no replacement for um a randomized control trials. This was a really nice um paper that was in Jamma cardiology last year uh led by um Bobby. Yeah, and some other um you know, great uh team uh that really just showed, you know, he his end statement is randomized clinical trials and mechanical c circulatory support devices will allow valid comparisons across Canons treatment strategies and help resolve ongoing controversies. The, the short version is um if you look at uh registry data, I think we've all seen, I can prove, you know, anything I want to and two reg four registries can show four contradictory different things, you know, show a north, south East west. And so I think we just have to know what we're using registry and randomized data for. Um uh th this is a slide that uh I like the slide, but obviously, it needs some updating, but it's nice because it shows all the trials. But now we have results of trials and I think the key piece is the picture that shows why have there been a lot of neg negative trials of temporary mechanical circuitry support? So, um e either we're, you know, um including or excluding the wrong patients as sort of alluded to in my uh uh showing you of whole graille slide. Um you know, are, are these apples, oranges, bananas and pineapple patients? Are they the same, same shock severity? Um And uh you, you know, how long do trials take to enroll? And what are, you know, some of our challenges in that regard? Um Obviously a lot of talk about the danger. Uh recently, I think there's, you know, that could, that could take up an entire hour, I I will say, you know, kudos to the team that was a, you know, decade long trial, Jacob Mahler and then uh Moller and then, you know, rolling it out from Denmark to um Germany and elsewhere. Um but also, I think trying to narrow the focus and exclude cardiac arrest and exclude RV failure. So really just looking at a left ventricular predominant shock and why I think that's important is again, if you're choosing a specific device for your patients, it's important to not do my patients match the patients in this uh clinical trial uh or not, but really kudos to all the investigators and I would be really uh interested in seeing uh hopefully recover four um uh uh still get takes off. So when you think about treatment goals and cardiogenic shock, I really, really like this uh um uh picture uh because what's the first step avert death. So I always, you know, uh talk with colleagues and trainees and I say, you know, much of life is binary and you just, sometimes it's a series of binary choices, you can't have 10 things to choose from. So first stop them from being dead, you know, uh then you can move on to the next step. But along the way, we're trying to not just, you know, facilitate myocardial recovery but protect the noncardiac organs as well and also circumvent complications of all the different, you know, devices and therapies we use, which is are many and particularly when patients are in the hospital for 1234 weeks, you know, those effects can add up something that is, you know, very important to me. And that I'm passionate about again in pushing um you know, systems of care and part of my impetus initially for um having protocols pathways and a shock team is that I think, you know, I I was really bothered by it and I think we all recognize that there are a lot of very, very undesired delays in recognition of all kinds of things, but particularly cardiogenic shock where, you know, delays really make. Um uh you know, a big difference, there's barriers to access to care, there's heterogeneity of care between institutions but also within institutions and these are not driven by, you know, medical factors per se. Um And so I think, you know, one of the reasons to me to think about protocols and teams and networks is to elevate the floor of care for everyone by some standardization, which will evolve and change over time as we hopefully learn more. And then maybe we're not stuck in that 1945 you know, protocol from Cook County, but we've moved ahead. Um And I think we know by now we've seen some good data from Detroit and then the National Cardiogenic Shock Initiative. Um you know, uh University of Utah looking at their refractory cardiogenic shock population with again a before and after um registry study looking at significant improvement in in hospital mortality, similar of before and after, you know, protocol and team uh registry evaluate retrospective registry evaluation from University of Utah. Also showing, you know, significant improvement in um in patient in hospital survival for cardiogenic shock uh patients. And then get our results from um Iova and then a lot of pooled um data that people have from Shock Working Group in C three TN. And I'll show some of our specific data later. Uh This was a nice um paper that was just published by a AAA big team in the journal of American Heart Association. And I think it just looked at uh again, there's lots of places doing teams and obviously the, the authors of which I was not one but the authors, you know, came partly from these institutions. So they're sort of highlighting some longer standing institutions that have um uh not only demonstrate effective use of shock teams but have published their data. And there you could see some common threads about um you know, multidisciplinary uh groups. Um And you know what some of the leadership structure is, the importance of having algorithms, a quality review um process uh ease of access. So ours is one call shock phone number, you know, I would say when you call 911, they don't tell you to call, they don't have like 12 numbers to call, you call 911, you can scream and drop the phone and, you know, the whole plan is for someone to respond. Um There may be some questions but they're not taking you down. Um You know, the, the 10 question tree um partnership, uh bigger hospitals, smaller hospitals, remote central, you know, together and that's very bidirectional uh education. So we all get better together. Um And then again, I think, um you know, research virtual, there's a lot of other things, but this was a nice paper to kind of look at um what some folks are doing w when we from just a very practical standpoint, think about our shock call. So we've um decided that this is a one call. So we leveraged already existing phone systems. So we already had a phone system that you call in for semi or you call in for trauma. And so you already had an operator and then the operator could just get the key people on the phone. So in this case, we decided, um you know, critical care, advanced heart failure, um interventional cardiology and cardiac surgery. And sometime this, sometimes this is specifically for transfers, sometimes it's consultation or liaison. So again, I told you in the beginning, I'm in private practice. So now 90% of the time I'm at um um I know the sha heart and vascular where I have on site va transplant, cardiac surgery, ECMO. So I, I'm sort of swimming in all the possibilities. Um, but I, I take call at multiple other facilities and in the past I've spent time in other facilities. So I might be at a site that has a balloon pump. Only that kind of has an IC U but doesn't have nighttime coverage that really is not comfortable with. Swan has never used large bore access and I could go on and on and, um, I'm not less intelligent if I'm at that person at that facility that day. Uh But I'm less well resourced. And so this, you know, sometimes the phone call can help with consultation, liaison, transfer, inappropriate transfer decisions. But I think it's also helps to be a lifeline between, you know, uh big and small centers. And over time, it's really important to build those relationships if you want to build a network. Um I'm gonna use this quote fully acknowledging um that uh Albert Einstein actually did not um uh say this, but uh you know, everything should be made as simple as possible but not simpler. So I kind of mentioned the, you know, having things at an eighth grade level and how even when I talked to my kids about trying to focus on, you know, binary choices as part of your decision making um tree. And I think we tried to do that in our um shock algorithm. And then other things I think, you know, if for the most, I, I, you know, I think if you came up over to Iova and said, who's in charge of the shock team? I, I'd probably tell you everybody in house, no money would have an answer. And that's not because it's leaderless or rudderless. I think it's because we really have put a lot of effort and time into having a, a close team personally, professionally, uh, that kind of, you know, crosses, um, specialty, um, and, you know, career, um uh boundaries. And then again, I'll say this, you know, everyone sort of heard this, people don't rise to a crisis, they follow the liberal level of preparation. Uh So this was a big key for me in the, in the military. But again, I think this is if you have a protocol, you have a plan, you have a system of care, you have a network, then that's what you're gonna leverage. Um when somebody's critically ill, this just a snapshot kind of our timeline up through 2022. Um So we're, you know, averaging over 400 patients uh shock activation and, and shock patients per year. Um Now, so, you know, we add another 400 to the number at the end there. But, you know, it's really like how we, we initially stakeholders met said, what should our shock team, you know, look like, what is our state of affairs currently? Let's build an algorithm which was fairly contentious. Um I think um and, but we, you know, arrived at what I think is a good algorithm. We went live, we had constant evaluation and assessment. We had ongoing education, sort of reed education. So we didn't get complacent. Um And then we started evolving from having, you know, uh spreading out to a larger network and then getting feedback and sort of build as we grow. Here's our protocols. This is our v you know, version three that we've kind of developed. So we have these pocket cards, there's posters, I think this is helpful to focus people having these, you know, posted in various care um locations about, you know, what is the role of the shock team? Again, binary de decision making is as heart failure is acute. M I um is the patient in shock, is the patient not in shock? Do we think they, you know, would need, you know, uh uh immediate consideration of circulatory support or, or not? Um So obviously, there's a lot of background, complex decision making that happens, but there's some key binary um decision points that I think are important. And then our latest iteration again, acknowledging that uh we've learned a lot both locally and you know, globally about the differences between acute M I and heart failure shock. But also that we've seen a switch from 60% acute M I to 60% heart failure within our own institution and our referral network, we sort of, and then with the development of sky stages to sort of build in. Um Can we add some structure about how we communicate about shock, how we think about shock and how maybe we select devices? And I'll say some of these device selections are not purely based on science. Some of this is what we found works for our institution based on our culture, based on our expertise um and our, you know, uh capabilities and what can we provide 24 7 along the way, the uh you know, we went from when I um started attending in the Coronary Care Unit. Um I joked that it was, you know, that was for stable healthy patients, eating a turkey sandwich on their own after a K of mind and watching TV. And now it's, you know, it's, these are, you know, ECMO vented swan uh impala, you know, blo palm vasopressor inotrope uh patients. And, and it really been in uh Reddic transformation just in the past eight years. And importantly, along the way, we really had to grow and build the step down units too because if you raise the acuity, so significantly of the intensive care unit, if you do not in parallel, raise the acuity of those other step down units, then you have a problem because you don't have a place for um you know, for those patients, those other patients to go safely. So that's been a a process and I really give a ton of kudos to our cardiac uh critical care and our heart failure folks um for really building this uh structure and it's a really fun part of my job to be able to work in the cardiac IC U. And it's uh i it's kind of amazing to reflect back on what that looked like. Um I can't overestimate the or overstate the importance of after action reviews or whatever you wanna call it, call it a quality improvement, quality assessment. But whenever you're going to institute a change and for us building a shock team was a big change. We initially met every two weeks for the first two years and we did 100% case review. Um So what was working, what what was what was not working? What can we do better? This was really, really important to stop bad practices early. This was also really important to uh encourage good practices to build on successes. I think it was also very critical to uh collect our data because some people that were not invested or not interested in the shock team would point to, well, this one case but and we could say counter that. Well, well, here's our data. Um you know, other people would make statements again, not based on data, either pro or con. And it was important for us to have data to back up what we're doing and for us to evolve over time, become a learning organization and get better. And it's really helped build a lot of teamwork, especially between the four specialties. Um As our uh program grow, it grew, we just sort of focused on landmark cases. And we have, you know, um uh some people that sort through everything to pick out, you know, common themes and some of what we looked at again, I showed you the slide about some of the undesirable, undesirable care variability. And some of it was, you know, this Swiss Cheese model people talking about latent conditions, active failures, trying to figure out how do we you know, plug the holes. Some of it was with protocols, some of it with hard stops in our algorithms. So one thing we did early in the Cath lab is if someone's on inotropes vasopressor, that's a hard stop, they cannot leave the Cath Lab, they will not be accepted to the IC U. You need to put a right heart Cath right heart Cath, you cannot, you know, get them to the cardiac IC U without reporting the numbers. Um And then if the numbers, you know, are uh indicating cardiogenic shock, you can't move forward without activating the shock team. There were probably some eye rolls by some people in the beginning. But ultimately, we made this a fast, easy streamlined system. And then I think also if people are gonna try and not follow the program or realize they will never win, it just changes human behavior. And now this is much more reflexive. I'm not here to tell you we're not perfect. Um, or to hear our protocol all the time or things don't slip through, but we've definitely become much, much better and we've gotten much better at plugging some of these different holes and finding new holes. Um, you know, to plug over time. So we published this a couple of years ago. Uh hopefully in the next 12 months, we'll be publishing our six year data. Um But, you know, looking at, well, what about when we grew from a, you know, um shock protocol program to center to AAA network? And this is a big debate, you know, should every hospital have be a shock center? Should you have a shock center for every region? What is a hub and spoke? A lot of people don't like um you know, being called a hub and spoke because a lot of people don't like being called to spoke, you know, so then there's a lot of, should we on a level one, level two, level three? I don't know that there's ever gonna be a term where someone's not gonna feel special. But I, I do think the point of collaboration is uh important. And again, guess what? We've already demonstrated this with, you know, m I um with stroke with, with trauma. So it's not, you know, something new uh that we can improve care. Um And again, our, you know, our um hypothesis and been demonstrated in our network is that by standardizing care and building a network, we can raise the floor of care for everyone and we can improve, you know, overall um survival. And again, this was our um couple year data published in 2022 as I mentioned, um you know, we're uh hopefully get our six year data submitted this year and publish either later this year or early next year. Um When you talk about some of these level one level two, level three or spoken hub, I think uh you know, what is, what is that, you know, Marvel heroes that Spiderman, you know, great responsibility come with great power comes great responsibility. So I think having, you know, the difference between duties and responsibility, so you large center that's a V or a transplant that's accepting patients has a duty and responsibility. Sending centers have duties and responsibilities. And it really just highlights the importance of the importance of collaboration and working together. And I think this also has a great opportunity for building uh collegiality for building relationships. Um And it really has to be um bidirectional and you know, having these uh you know, again use another military term, you know, teams of teams. So you have expert teams that are then working together to build an even, you know, better team. And, and you can see this wheel of uh of different people involved in the care of the cardiogenic shock patient. Uh Th th this is not all this is not gonna exist at every single hospital, right? But it should hopefully exist in every region and how you leverage and work together between um you know, sending and receiving centers is critically important. So here's a snapshot of uh us. So, um again, I, I, when uh you know, I, I got there right at the end of 2015, a number of us sort of like minded individuals started talking about a shock team. Um We were able to start through 2016 building some of the framework and go live in January 1 2017, we looked at our data retrospectively and as best we could determine um by, you know, chart review and, and, and data review looked like our um baseline survival was less than 50% that probably frankly was pretty accurate because when we were started tracking 100% of patients. Um in 2017, we sort of climbed up in the year total to 58%. So it seems real that we were below 58%. We continued to build and refine quarter by quarter by quarter. Uh And uh other than a small, um you know, dip in COVID, I should actually move that over um to 2020. Um But um we've been able to maintain survival over 70%. You can also see the number of patients managed. We've grown significantly and we've grown from just having a couple of centers transferring to now, you know, over, I think we have like 4748 centers in Virginia, West Virginia, Washington DC, and Maryland. So I think to me what demonstrate is we can improve survival um that the building a shock, you know, um protocols, team center network is doable. It's sustainable for multiple years. It's scalable. So you can scale it geographically and by a number of patients. Um And if, if you do it the right way and again, I would say for anyone starting a shock team, you got it, you must, must track your data and figure out what's right, you know, for uh for you. Um I've also said in, um you know, in a lot of venues that this is also discussion with administration. So, uh you know, I sort of cynically say, if you want the best survival in your hospital, you would station people outside the emergency department and anyone who looks remotely sick, you'd smother them with a pillow and you'd let only healthy people into your hospital and then you'd have great survival. Now, obviously, that's not a good long term strategy. Obviously, that's not what we're in the business for. We want to get the sickest people in and we want to take care of them. What that may mean in the short term is, you may see more people die in your intensive care units, your operating rooms, your cath labs, but if you're tracking your data, you should see more people alive overall in your community. And that's really the key that I, I think we're all looking for. Um I'm just briefly gonna mention something that I think is really cool. Um A lot of a couple of our heart failure uh folks. Uh Yeah, it is. So came to us from um uh Henry Ford and uh two of our great uh uh nurse practitioners um are uh looking to start a, a cardiogenic shock survivor clinic. So I think for the sickest of the sick, yes, they're seeing cardiologists, a lot of them are feeling heart failure, a lot of them, but a center where they can sort of have a lot of the multidisciplinary care needs that they may need for. Um what can be a very, you know, long path to recovery for some of them. Again, there, this uh highlighting this paper again that just came out from the journal of the American Heart Association um that, you know, the paper was focused on the need for from a research standpoint of cardiogenic shock collaborative to decide what our research priorities. But to me, I think it was a nice meeting of the minds by a group of folks that really looked at um you know, what is the data that we have about shock team and, and validate a lot of things that, you know, we and others do. So, you know, what does activation look like. What is the team um look like? How do we collect data? How do we treat patients? What are the gaps in knowledge and you know, where, where does all of this uh plug in with the care of the um patient? So I'll, you know, pivot back to uh uh conclusions and this is a, you know, quote stone from a lot of the early, you know, military and, and trauma um literature is, you know, alive, patient above all else. So first, you know, patient alive, um you know, it really important to have human dynamics. We went from very low Swan Gans use to our goal for 100% in shock. And II, I think we're well above 90% and I think that has been helpful for building the expertise for learning, for growing and tailoring our therapies uh and tailoring that uh tailoring both uh pharmacology selection and a device selection. And we've all sort of learned and uh grown along the way both internally and I think sort of nationally there's a lot more discussion and internationally about, you know, not just shock, shock shock, but what is the, what is the, you know, ideology of shock? What is the phenotype of shock? Uh What is the stage of shock? Um I, I'll never forget when I, you know, my very first shock calls when we stood up the team and I'm in the Cath lab, put in a device And, uh, you know, I'm thinking, I'm awesome, saved somebody's life. And one of the heart failure, folks, you know, somebody's asking me, are they 69 or they 71 do they smoke or not smoke? And I'm thinking, what the heck is the difference? And, and, but I learned along the way they're thinking about the heart replacement strategies and some of our early shock calls was interesting. You know, we kind of joked about this, you know, the interventional cardiologist had certain questions, critical care and certain questions, heart failure, and certain questions, cardiac surgery and certain questions. And then we sort of built this Venn diagram and we realized maybe we didn't know as much about the other specialty in person as we thought we did. And then it, so it's been a really great learning and collaborative process together that I think has had a lot of spill over or, you know, halo effects um to other regions of, you know, medical care. However, you wanna, you know, say that I think also in shock, you have to recognize there's not just cardiac pathways to death, but there's noncardiac pathways to death. There's a lot of them patients are in the hospital one week, two weeks, three weeks, four weeks, you know, maybe more. Uh and so a big piece of that is identifying, preventing mitigating salt, you know, addressing complications, trying as best we can to think, you know, multiple steps ahead. Uh again, to me, I think if you're trying to influence human behavior and you're trying to build a protocol and try and keep people within sort of lanes, so to speak, having a shock protocol with some, you know. Yes, no. Left, right. Hard stops. And binary choices is very important. In, in my opinion, in the beginning, I think if it's too complex or, you know, too many, um, decision trees, then it can be overwhelming and that it may be different where you are in your um building process. But I think particularly if you're talking about introducing this to emergency department, pre hospitals and you know, internal medicine, you know, um you know, some of the, you know, outpatient cardiology that has to be, you know, very straightforward, there may be a sort of behind the scenes algorithm for the advanced heart failure person, but that's fine. That shouldn't be the forward facing document. In my opinion. Um At the end, I think we have to acknowledge uh these are very complex patients with again, multiple um pathways to, you know, death and disability as I mentioned, and there's limited randomized control trial data. Um but, but growing and again kudos to investigators. So I think we have to just continue to build and learn together and yeah, my strong opinion is whatever you do. I think it's important to track your in your data by um hospital by health network by system because your challenges opportunities um complications, successes are probably gonna be a little bit different and there may be some unique um differences compared to uh another center. Um So, lastly, I think, you know, whenever any of us, uh you know, somebody gets invited to speak, they're obviously speaking on behalf of hundreds or thousands of, of people and uh patients. So, uh just, you know, a, a big kudos to everyone. Um you know, in my group, Virginia Hart and the I know a Shar Heart and Vascular um institute uh you know, team that is, you know, we're all working collaboratively to take care of these patients. So, uh thank you. And uh I think I left uh uh hopefully enough time for questions. I'm gonna stop sharing. All right, Alex. Um Thank you very. Oops, let me get my video and stuff back in order here. All right. Well, thank you very much for joining us. And I think you did a phenomenal job of taking a very complex topic, not only reviewing the, the science and some of the literature behind it, but really speaking on the practical aspects of how to improve care for these patients. And I think it's one thing just to review the data, but your insight into how you made your program so successful um was was eye opening. And exactly, I think what we were all hoping for. So, thank you for that. Um The CME code is a reminder is 89783. Again, that's 89783. Feel free to leave any questions or comments uh in the Q and A or the chat box below. Um In the meantime, Alex, I'm gonna start with uh with seems so simple yet. It, it, it took a, I think a while for folks to recognize and that's the fact that all cardiogenic shock is not the same. And, and you really eloquently pointed out the importance of differentiating acute M I and chronic decompensated heart failure. And you know, I wonder if over the years us trying to lump all this together and make it a just one category um was actually complicating things. And if you think about them mechanistically differently, the goals sometimes are, are different between them and what we're striving to achieve. And so I think you very eloquently pointed that important uh aspect out. Yeah. No, II, I agree. And I think um this goes back to you, I have learned so much and I've learned so much from my, from my colleagues and we've learned so much from patients and I think that's where we've really grown. And, and that, you know, the last two slides of the algorithm where I showed you, we now sort of break out there's the initial hate shock, right? Um You know, dead alive, heart failure. Qm I um you know, do they meet criteria for shock? Yes. No mechanical circular support. IC U fine. But then the next step is OK. Now, when they've been sort of funneled to, for lack of a better term, a, a more specialized arena or group of people, then you have a more complex algorithm and we really realized the need to separate that out between heart failure and cardiogenic shock, both for some immediate decision making. Um and some longer term, uh you know, a very obvious example is if you ask someone, um is there a role for balloon pump in cardiogenic shock? That is a almost an absolute yes. No, there's no zero or 100 right? But it's closer to 100 for one phenotype and closer to zero for the other phenotype. Uh you know, um what medications are you gonna use? What? Uh uh and, and, and that again, if you're lumping them all together, you're gonna be scratching your, your head or Bill o'neill uses a great, um example of somebody with, you know, inferior eye and, and really almost wholly right, ventricular shock very early on in, in, in Pella use and put it in impala. And then what happened? The patient completely spiraled to death and they said the device doesn't work as well. You know, there's also got to be some super tutorial thinking, um, you know, uh here too and, and that's, and that's a process, but I, I think we've done a good job discussing it, you know, multiple heads ideally are better than one, particularly if the heads learn together. And the, the swan uh usage has been uh that, that's really been very, very key for us. I think Alex walk us through if you don't mind. A, a an example call that one of your shop members may receive and who takes that initial call? How do you then spread the word or activate the rest of the team? Um Does the patient always go to the IC U Cath lab? Maybe the, or walk us through if you don't mind, kind of how your, your, your workflow is on the shot? No. Great, great question. And I think again, um, and I'm even gonna dial back one step because this is where people get really, you know, hung up and they, they'll say, well, I can't, I can't do that. That's too much. There's too many different things. And I say, ok, uh, so I always say the same thing. What, um, do you do you have a system for dealing with ST elevation M I? And they say, well, of course, I do. Ok. So stick with that system. Do you, what do you do with sick patients? Well, you know, who identifies them and how, who gets called over the intensive like, ok, so now we've established, you have a system for sty, you have a system for sick, sick patients. So don't re invent the wheel, you know, think about that. And that's kind of what we started. So when we started in education tiers was um one thinking about um you know, who do we educate? So we went to, we did out in reach outreach to, you know, emergency department to house staff or increased recognition. But we really highlighted again, if this is the pathway for calling, you know, critical care for sick patients, then just call critical care, then we can educate a smaller group of critical care about cardiogenic shock. If you have a Cath lab, a semi activate semi. Now we can educate a smaller group in the Cath lab about cardiogenic shock. And that made the training, you know, um easier. So who activates. So sometimes it may be from the emergency department. Although, um again, that's probably less so because they're just saying, hey, there's somebody sick, they're critically ill. And so, you know, oftentimes that may be the intensivist in the Cath lab. Um So in the Cath lab, you'll have, you know, the interventional cardiologist will sometimes, you know, um will call, um you know, the intensivist may call from the emergency department. Somebody may get to the, you know, IC U and get call and then the majority of our call of our calls now are external. So those may be a lot more differentiated. There's someone in a Cath lab somewhere else who just says like there's somebody sick and I, I'm worried or they may be in an IC U, they're sick, you know, and I'm worried or they may still be in the emergency department and say, hey, I've got, you know, I called my intensivist, but this person is really sick and I'm worried and what we really tried was this one call system, you tell people, you know, call these 10 numbers human nature, even if it's the best thing for the patient. If you put, if you disincentivize good behavior and put up a bunch of hurdles, I'm not going down that pathway. So you call the operator and then the operator, you know, calls, you know, it gets multiple people together on the line. We've tracked that we track um if there are slow responders, um then that's a separate conversation about, hey, you took, you know, everyone else took 30 seconds to answer their page and call and you took five minutes. Let's, you know, that that's a separate, you know, one on one chat. So things like that and to try and keep the conversation um focused. So it's supposed to be about um you know, collaborative um uh uh uh but rapid decision making about the initial um consensus plan of care. So we don't need to have a discussion about the whole spectrum. But, you know, OK, this person's 100 or they're 60 that, you know, do they have advanced therapies or not? Do we, I mean, are we thinking about transfer or not transfer? Can we help you make a decision right now with the patient? But try and keep that focused. Um, I think, you know, we've tried over time and we've had some offline counseling where it can be, it can be easy. We've all, um, been on both sides of a 2 a.m. phone call where we're cranky and, you know, sometimes you've had someone be less than respectful to you, sometimes you've been less than respectful to someone. Um, and I think that's also been a big thing that we record all of our calls. So sometimes we can go back and, and, and sort of learn together about that be because I think that's a key piece of it too and also acknowledging um, where the caller is. So I will ask questions, um, like, let's say from Cath Lab, you know, hey, I'll, I'll identify myself as an interventional cardiologist. So I'm already, you know, breaking down that comfort level and I said, do you know, do you have a balloon pump in your Cath Lab? Yes. No. Ok. Do you have this? Yes. No. Do you, do you have an IC U? You know? Yes. No. Do you have a night time coverage? Yes. No. Do you have, are they in houses? And that can also frame for everyone else because that's gonna guide decision making about what our recommendations about on site therapy versus, you know, transfer is. But I think the key is to try and get to have everybody on the call together. Keep it brief, get everybody on quickly, keep it brief, keep it focused and keep it focused on, you know, accept, not, accept immediate consensus, you know, plan of care, then once they're in our facility that may change, you know, if I'm in the intensive care unit and they're already routing one way and heart failures by the bedside, you know, do we have a full team activation all the time? No, we sort of had many conversations like everyone else does, you know, along the way and then if we feel we're at a really big branch point, then we may reactivate, you know, um everyone else, I will lastly say there was a period where we said, you know, what very few of these patients uh go directly to the or so let's just make life easy for the surgeons, take them off the call and we did that for a while and to our surprise and usually when I tell other people to other people's surprise, they specifically asked we want back on the calls. So they were basically saying we want to get more of these calls, you know, in the middle of the day, in the middle of the night because it was better for them to know about a patient early rather than later. Because the experience from 10 years ago was every, you know, by the time they were getting engaged for, you know, for go to the or, or uh you know, it may be too late. And, and since, you know, they're primarily cannulated ECMO as one example, you know, that's something that they want at least be tracking these patients early. So I think that was very validating to me that when we did a couple of months, a couple years ago, of them off the call, they said no, we, we, you know, we want, we want back on follow up to that, um who's sort of quarterbacking your, your organization of the, of the uh of the shock team, including data gathering, um keeping track of the outcomes, analyzing the the results. Is there, is that one of the Docs, is there a coordinator or a nurse? Is there someone that you have identified as? Yeah, I think, I think so for the quarterback for the phone call, that's kind of gone through a little bit of an evolution. I think we kind of decided our are the uh the uh IC U management for the cardiac IC U at the, at the, you know, hub hospital is a co management model. So like when I round, it's an intensivist and you know, me rounding together. So it's a some sort of cardiac specialist and intensive specialist and that, that really works out well for us. So one person is an attending a record, one is technically a consultant, although you know, who is actually managing more is different, but it facilitates to account for your time and billing and other you know, practical realities, um, that we all deal with. Um, so in general, we try and have that group. Um, you know, one of those two be the quarterback, but it's pretty fluid, I think by now, you know, most of us all pretty much know each other. So, you know, if somebody, if, if it's clearly in somebody, one person's wheelhouse, there may be a more dominant person that, you know, speaks up and ask questions. But I, I think if you asked on paper, it would be with the, the cardiac intensive care unit, one of those two attendings, cardiac critical care uh or cardiology, uh probably officially cardio critical care. But again, you know, uh I, I think if this is clearly like a, you know, chronic heart failure decision, if there's clearly a surgical issue, there's clearly interventional cardiology. I think that can pivot, you know, pretty um pretty quickly. And again, that's sort of evolved um over time. So there's a lot less speaking over each other than there may have, you know, once uh been, but that's been an evolution and Alex, how, who's keeping track of your results and your outcomes? Yeah. So, um so initially, that was really challenging, actually, um uh uh one of our interventional cardiologists, you know, Benham Taani, God, God bless him. I mean, he was literally tracking the data, him himself and, you know, in his, you know, free time and that, that's how it started and then we kind of, there was a mix of us and people collecting data. And then I think that came to a point where, you know, it sort of felt like the, the institution was cheerleading highlighting the program. We said, great, if you're gonna do that, I have, you know, we have a request, we, we need, you know, we need resources. So we've demonstrated our value, we've demonstrated XY and Z and uh so then I think the first thing um we did was um uh hire, you know, someone who is already internal of the system, Carolyn Rosner nurse practitioner. And that was key. She was focused, she was dedicated. Um And really, um although she did have like three or four other jobs, I think focused on, you know, the, the structure, the framework, the data tracking, uh the algorithm, the process. And then, you know, she sort of became um helped recruit additional people w which were multiheaded between, you know, heart failure, cardiac surgery, interventional cardiology for program building um for inpatient and outpatient combined things. But, but that really was key, that was not gonna be sustainable if you wanna talk about, you know, the um day to day care versus a program that grows and builds and, and improves in data tracking. And that was something we really, really hammered home because, you know, I I'm sure other businesses are the same. But, you know, health care, my experience has been you know, I could cost you if I say I'll save you $100 by the end of the month. You don't care as long as I save you a penny today, which makes no sense because all of us would take that deal within our house. Um But, but that was really, you know, beating, you know, beating that drum, uh a lot and beating it with a unified voice and beating it through separate departments. So that message was very, very clear and some of it was even saying things like, look, if, you know, we don't have to have a shock program if you don't want one. And, and, and so, but that, that was really key and I mean, look big structural heart programs. Does someone not have a coordinator? Um, you know, cardiac surgery? I, I mean, you could go on and on and on. So I think that you can just really point to how this exists in other realms and it will be of use and then track afterwards. So it was very clear immediately that they were worried. Well, that's what this person gonna do. They're gonna be bored. Well, they weren't bored and they had plenty to do. In fact, it was too much for one person and, you know, but that's again, something to track along the way. I see. I love to get your thoughts. Um, first on the sort of national Cardiogenic Shock initiative and trying to protocol, the care of these patients. So I give them credit for at least starting to develop a protocol. Um I think a lot of folks that they felt that their protocol was too liberal. Meaning if you had an LVDP of 16 and a cardiac index of 2.1 that it was a, the next step was boom Impala and it sort of took out the cerebral aspect of it. It took away the, the fact that you were there next to the patient. What do they look like? Um kind of what's the whole package? And, and I it's nice to see that you guys sort of tighten that uh inclusion criteria up a little bit. It sounded like your cardiac index is more like 1.8 in the setting of an acute M I. But I'm curious to get your thoughts on trying to find this balance between a protocol for cardiogenic shock and then individualizing it, you know, we won't even get into cost or other factors. And the reason I bring that up is we know there are, there are side effects of these devices. Um There are real complications and it's a trade off and we don't want to over implant, which is gonna lead to a lot of unnecessary complications. At the same time, we don't want to under implant and potentially risk the outcomes um their survival. So I know it's sort of a loaded question, but I'm curious just to get your thoughts uh on that. No, I think it's a great question and an important question. I mean, one, I, you know, start off by saying, uh one of the great accomplishments of the first forget about national. But the Detroit Cardiogenic Shock initiative was basically taking us a city and saying people have widely disparate outcomes and that's not OK. Now, we don't know what the answer is, but let's at least say if you come in with acute M I cardiogenic shock anywhere within the Detroit metro area, let's all agree based on what we all think, you know, sitting around the table, what we think now is the best. Let's do this and at least work on that and then we'll track our data. So regardless of anything after huge, huge, you know, kudos, but you're right, that was designed initially for that purpose for that population of acute to my cardiogenic shock. Um And I think it was really instrumental in helping developing the idea of recognition of shock, the importance of consideration of mechanical circulatory support, the importance of a protocol, but it doesn't, you know, end there. And so I think, um you know, for us again, a Q to my acute de compensated hard fighter chic big big spectrum. And this is where again, shock working group C three T and other people have really grown our knowledge and our protocol has evolved and changed. And so there is no perfect device. So um there is no perfect drug, there is no perfect um patient. So again, to me, this goes back to um looking through internally, we had, you know, we are an ECMO um heavy and centric program to a large degree because we had a well established existing ECMO program build on your successes. You know, we sort of took tandem out of our algorithm, you know, some years ago, because when we looked at, you know, the number of tandems that I put in and how often do I cross the septum? And do we have 24 7 capability? But we don't, so that didn't make sense for our institution, you know, what was our experience with impala and again, part of that and balloon pump and in which patients. And so this to me was key about, we really changed what we did over time and we were noticing complications. We also, once we started large bore access, we did a whole training program for large bore access, ultrasound guidance. Um uh pre close, we did co we consulted vascular surgery on every indwelling device. In the beginning, we had, I mean, these were all team discussions to do this. Um uh because you're right, there's no free rides, these are sick um uh patients. And so we gotta figure out where we're, you know, harming or not harming. I I, you know, again, randomizing and in shock trials is incredibly hard because of all those pathways to deaths. And there's, if you just pick one thing, I don't think that's gonna do it. There's so many different things. So that just makes it super, uh it is super hard and so yeah, collective wisdom is gonna be absolutely key. And there's no magic bullet here, I guess in our, in our closing moments, if, if I can get your quick thoughts on, on danger shock, you know, I think as interventional cardiologists, we felt somewhat vindicated that at least there was some, uh, some study that finally showed, uh and, you know, a survival improvement with this approach. Yet there's a lot of subtleties of that trial that, that need to be discussed in terms of what the, the standard of care arm received, the complications associated with it. So, um we could talk an hour just on the, on that trial, I'm sure. But I'd love to get just your kind of high level thoughts on the study. Yeah, my, my, my, my 30 seconds, which would fit with our experience is that for acute am my cardiogenic shock uh in patients presenting, you know, early, um that meet criteria for cardiogenic shock that don't have RV. Um, you know, involvement that don't have cardiac arrest, um that otherwise are not people that are gonna for sure die from any other things, um that, you know, early use of mechanical circulatory support as part of a protocol as part of good follow on IC U care with, you know, good vascular access training and, and protocols and post device management. Um uh You know, II I is probably going to offer a its survival benefit towards, you know, for those um patients. Well, Alex, I, I thank you very much and, and one little nugget that you gave us I really enjoyed was your heart stop for IC U acceptance. You know, we, we've, we've sort of spoken about this concept and kind of encouraged it, but we haven't really empowered our IC U. Um And I really think that that's a, that may be the next step to really kind of uh kind of elevate the care of patients coming in there and really making it a requirement. And, and I think like you said, once it's, it's commonplace that uh it, it'll just become sort of natural workflow over time. But with all of that, I, I really thank you for joining us this morning. I know you're, you're busy on the school field trip and yet you took time out. Uh So we appreciate it and I look forward to continuing to collaborate and hopefully uh see you in person sometime soon. Great. Thank, thanks so much for having me in, in person. I really appreciate it. All right. Thanks, Alex. Take care. Enjoy Philadelphia. Thank you. Published April 23, 2024 Created by
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