2023 SCAI SHOCK

Rapid Shock Transfer Process Success Using a Heart Team Approach in Non-Academic Hub Center

Tulio Diaz, M.D., Texas Health Presbyterian Hospital Dallas, Dallas, TX
Tulio Diaz, M.D., Texas Health Presbyterian Hospital Dallas, Dallas, TX

Title
- Rapid Shock Transfer Process Success using a Heart Team Approach in non-Academic Hub Center

Introduction
- 61 F with multiple comorbidities admitted to STEMI receiving center with NSTEMI. Cardiac cath was complicated by Type F LAD coronary dissection and vessel closure following rotational atherectomy, patient developed cardiogenic shock. Impella CP was implanted, and rapid transfer process to Shock hub was started while patient was in cath lab. Receiving center Shock hub heart team at bedside upon arrival with team decision to escalate support to Impella 5.5 given EF 15%, ischemia noted to the extremity with Impella CP and multiple vasopressors. High risk PCI to LAD was performed with 5.5 support during admission. Patient was discharged home on hospital day 10 with an EF 35%.

Clinical Case
- 61 F with multiple comorbidities admitted to STEMI receiving center with NSTEMI. Patient work up revealed significant CAD and low STS risk score; however, patient favored PCI. Case was complicated by type F LAD coronary dissection and acute LAD closure following rotational atherectomy and cardiogenic shock. Impella CP was implanted, and rapid transfer process to Shock hub was started while patient was in cath lab. Patient arrived on norepinephrine, vasopressin and phenylephrine and was without distal pulses by doppler to the Impella extremity. Initial CPO was 0.54 with CO 3 L/min and CI 1.54 via thermodilution method with Impella CP and pharmacologic support. Lactic acid was 11.9 upon arrival with shock liver AST 140 and ALT 66. Shock hub heart team at bedside upon arrival to receiving center obtained stat echo which confirmed no right ventricular involvement, severe LV dysfunction with EF 15% with anterior wall hypokinesis. Cardiothoracic surgery team took patient to OR for Impella 5.5 after team discussion of labs and hemodynamics. Escalation was complicated by unsuccessful Perclose sutures placed by referring center when removing Impella CP. Patient initially stabilized but subsequently decompensated requiring increased vasopressor needs and transfusion of blood products overnight prompting urgent consultation of vascular surgery. Patient was taken down to the OR promptly by Vascular surgery for femoral artery and vein repair. Vasopressor needs quickly decreased once hemostasis was achieved.

Within 12 hours of escalation to Impella 5.5, lactic acid improved to 2.2 and patient was weaned off epinephrine and phenylephrine. High risk PCI to LAD via radial approach, given vascular concerns, was performed with 5.5 support on admission day 5 and Impella was explanted on day 8. Patient was discharged home on hospital day 10 with an EF 35%.

Discussion
- Rapid transfer process using on call STEMI physician to guide plan of care and to involve advanced heart failure, CHIP specialist, critical care, and cardiothoracic surgery. Vascular surgery assistance for complications from large bore access is vital. Team discussions guided care for patient and led to a successful outcome.