Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Mechanical Circulatory Support - Part 1
21 Plays1 year ago
In the first part of this two-part series, Dr. Zanotti is joined by Bindu Akkanti, MD, an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at UTHealth Houston. Together, they discuss temporary mechanical circulatory support, an increasingly vital modality in treating cardiogenic shock and other subsets of critically ill patients in shock. Dr. Akkanti is the Medical Director of the Heart Failure ICU and the Director of Critical Care for the Heart & Vascular Institute at Memorial Hermann Texas Medical Center.
Additional Resources:
More about Dr. Bindu Akkanti: https://med.uth.edu/internalmedicine/2022/11/17/bindu-akkanti-md/
Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices. Pahuja M, et al. Curr Cardiol Rep 2023: https://pubmed.ncbi.nlm.nih.gov/36847990/
Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Salter BS, et al. Nature Reviews Cardiology 2023: https://www.nature.com/articles/s41569-022-00796-5
Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. Moller JE, et al. N Engl J Med 2024: https://www.nejm.org/doi/full/10.1056/NEJMoa2312572
Books Mentioned in this Episode:
The Alchemist. By Paulo Coelho: https://bit.ly/3yv4Zmt
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Understanding Mechanical Circulatory Support (MCS)
00:00:34
Speaker
Mechanical circulatory support is an increasingly important strategy for the treatment of cardiogenic shock and other subsets of critically ill patients.
00:00:42
Speaker
In today's podcast episode, we will discuss temporary mechanical circulatory support and its implications for critical care.
00:00:48
Speaker
Our guest is Dr. Bindu Akhanti, a practicing pulmonary and critical care physician.
00:00:53
Speaker
Dr. Akhanti is the medical director of the Heart Failure ICU and director of critical care for the Heart and Vascular Institute at Memorial Hermann Texas Medical Center in Houston.
00:01:02
Speaker
She's an associate professor at the UT McGovern Medical School in Houston as well.
00:01:07
Speaker
Dr. Akhanti is a master educator, a phenomenal clinician, and an avid researcher focusing on mechanically circulatory support and pulmonary hypertension.
00:01:15
Speaker
We are honored to have her as our guest today.
00:01:17
Speaker
Bindu, welcome to Critical Matters.
00:01:20
Speaker
I'm so excited to be here.
00:01:22
Speaker
Thank you for inviting me, Sergio.
00:01:23
Speaker
Thank you.
00:01:24
Speaker
Well, I know this is a topic that you are truly passionate and very knowledgeable about, so I'm sure this will be a feast for myself and for our listeners.
The Role of Intensivists in MCS
00:01:33
Speaker
But before we start, maybe as an introductory comment, could you tell us, Bindu, why do you think it's important for intensivists outside of cardiac ICUs to know about this topic?
00:01:47
Speaker
I think most of us that went into ICU medicine are really the original shockologists, right?
00:01:54
Speaker
We love when we are able to appropriately diagnose, manage, treat, prognosticate, and at the same time, look at the big picture and go,
00:02:04
Speaker
In this patient, this is the diagnosis and we are capable not only of trying to save them, but seeing what that future looks like.
00:02:13
Speaker
For most physicians, you know, it comes naturally, right?
00:02:16
Speaker
When you see a patient with lactate of 10, you're like, okay, this person is really super sick.
00:02:20
Speaker
But the reason every single intensivist needs to know about temporary MCS is that
00:02:30
Speaker
Recognizing which patient is in shock is one thing, but that's a global diagnosis.
00:02:35
Speaker
Buried in every patient that is in shock is the possibility that this could be a patient in AMI cardiogenic shock, or this is a patient in cardiogenic shock with other etiologies.
00:02:47
Speaker
This is a patient with biventricular failure.
00:02:50
Speaker
And if we don't know the phenotype at the get-go and what are all the available resources,
00:02:56
Speaker
then how are we going to take care of that person with shock, right?
Intensive Care Strategies for Complex Conditions
00:03:00
Speaker
So it's, you know, we all have a solemn duty to serve.
00:03:05
Speaker
And one of the ways that I've been really rewarded is to be absorbed into the advanced heart failure team here at UT McGovern and Memorial Hermann.
00:03:16
Speaker
As a pulmonary critical care physician, you know, there are very few PCCM docs that do this.
00:03:21
Speaker
But we've been doing this for about 12 years and the lead heart failure cardiologist, Dr. Carr, and the cardiac surgeon, Dr. Gregorick, when they first looked at us, they said, you know what, we do see this value that medicine intensivists play a role in this evolving field.
00:03:41
Speaker
along with our other disciplines, right?
00:03:43
Speaker
Like cardiovascular anesthesia plays a huge role.
00:03:46
Speaker
They take care of these patients upstairs in the OR, bring us brilliantly managed patients that are truly like, you know, we look at that ABG and go, wow, base excess of zero.
00:03:56
Speaker
This can't get better than that, right?
00:03:58
Speaker
But I think for the intensivist in the trenches, for me to look at a patient with shock and not only be able to diagnose what is the appropriate phenotype,
00:04:09
Speaker
And for me to relay this information to the other intensivists nationally and in your podcast internationally, this is a privilege.
00:04:17
Speaker
And thank you for picking this topic because this is only going to advance more.
00:04:23
Speaker
And whether or not you practice MCS critical care, I think that knowing what is available will help you save lives.
00:04:32
Speaker
Not to mention that it might be coming to your ICU anytime soon, right?
00:04:36
Speaker
Because it's also exploding.
00:04:38
Speaker
Yeah.
00:04:39
Speaker
Yeah.
00:04:39
Speaker
And it may not.
00:04:40
Speaker
One thing that I see when we do these national conferences or teaching is that it may not come to your ICU, but it's very fascinating that you may be covering for this patient in one of those nighttime shifts.
00:04:55
Speaker
And I think that's
00:04:57
Speaker
Nothing makes an intensivist more uncomfortable than a device that they don't know or understand.
00:05:02
Speaker
And I think that's in our DNA as an intensivist, right?
00:05:05
Speaker
We walk in, we're like, I know that's the CVVHD machine, that's the ventilator.
00:05:09
Speaker
And then what is this?
00:05:10
Speaker
How does it work?
00:05:11
Speaker
How do I use this data?
00:05:13
Speaker
And I hope that over the next few minutes, we can kind of talk about this in buckets and simplify it.
00:05:21
Speaker
And hopefully I'll give you a lens through which you can look at this field of MCS critical care and see it more approachable at least.
00:05:31
Speaker
Perfect.
Management of Cardiogenic Shock with MCS
00:05:33
Speaker
So just, I mean, in terms of basic definitions, before we dive into the different types of devices available today, what do you consider temporary mechanical circulatory support?
00:05:45
Speaker
So before we can talk about temporary mechanical circulatory support, I think we need to make sure that we all have an understanding of just cardiogenic shock, right?
00:05:53
Speaker
For us, it's simply cardiac pump dysfunction.
00:05:56
Speaker
You have hypoperfusion and tissue hypoxia.
00:06:00
Speaker
So we know despite what has been done, mortality is significantly high and as high as 50%.
00:06:09
Speaker
We used to say that, you know, metastatic lung cancer, those are like rapidly killing.
00:06:13
Speaker
They are.
00:06:14
Speaker
But AMI cardiogenic shock, especially when you don't diagnose it soon, is a very good thing.
00:06:19
Speaker
the mortality is even higher.
00:06:21
Speaker
So then you dive a little bit deeper and then you go cardiogenic shock with hemodynamics.
00:06:27
Speaker
If you have a cardiac index of less than 1.8 liters per minute per meter square without support, okay,
00:06:35
Speaker
And that's cardiogenic shock.
00:06:36
Speaker
But if you have less, it's still less than 2 to 2.2 liters per minute per meter squared.
00:06:42
Speaker
And that's, you know, shock still with a low cardiac index with support.
00:06:47
Speaker
You know that this is a patient that may need to go on something more than your optimal medical management.
00:06:55
Speaker
And before we even go into temporary mechanical circulatory support, I think it's really important that we come down to what is that optimal medical management, right?
00:07:05
Speaker
Our goals without MCS is simple.
00:07:09
Speaker
We want to increase the systemic perfusion.
00:07:12
Speaker
We absolutely want to take care of the plumbing with enhancing the coronary perfusion.
00:07:17
Speaker
We want to reduce the left ventricular filling pressure and the oxygen consumption.
00:07:22
Speaker
And most importantly, by doing all of this, we hope that we don't take this patient that has a hemodynamic problem and convert it into a hemometabolic problem.
00:07:35
Speaker
Dr. Kapoor's F1000 paper has really, really very, I think like the clarity of one image sticks to my mind where it is just
00:07:45
Speaker
You have a hemodynamic problem, which is just the index.
00:07:48
Speaker
But the minute that you have passive congestion of the liver, the kidneys are done, and now you deal with the mesentric, you know, the anisarca, and then now you have like a complete metabolic problem, right?
00:08:01
Speaker
So now how do you take that patient with those goals, right, of increasing the perfusion and enhancing coronary perfusion?
00:08:09
Speaker
What does medical management look like?
00:08:12
Speaker
Yes, we want to take them to the cath lab, do the plumbing.
00:08:15
Speaker
Yes, we want to give medications such as inotropic support so that we can improve the systemic perfusion.
00:08:21
Speaker
We want to make sure that their rhythm is adequate.
00:08:24
Speaker
We want to make sure that they're well diurezed and unloaded.
00:08:28
Speaker
And with all of this, if your index is more than 2.2, then you don't need temporary MCS.
00:08:34
Speaker
But to even get to that point, we are assuming that in the ICU, we've already done the EKG, the chest x-ray, the arterial blood gases.
00:08:42
Speaker
We already know with the surviving sepsis guidelines and stuff that we have the central line
00:08:48
Speaker
We are trying to understand our central venous side.
00:08:52
Speaker
You have an arterial line.
00:08:53
Speaker
And then you look at your preload, squeeze, afterload, rhythm.
00:08:59
Speaker
And in combination, is there anything else such as a pericardial constraint?
00:09:04
Speaker
It's really, really important to not just look at it at a single parametric method, right?
00:09:10
Speaker
So for instance, if you have tamponade, your entire hemodynamic variables and how you interpret them changes.
00:09:16
Speaker
And then if you have optimized your preload, if you have optimized your afterload and squeeze,
00:09:22
Speaker
and at the same time rhythm and that pericardial constraint.
00:09:25
Speaker
And despite that, you have evidence that this person is in cardiogenic shock.
00:09:30
Speaker
Then your next best thing is, have you phenotyped it in terms of the staging, right?
00:09:36
Speaker
Like we'll talk about univentricular and biventricular, but do you know what kind of shock it is?
00:09:41
Speaker
Yes, it is cardiogenic because I've ruled out everything else, okay?
00:09:45
Speaker
What kind of staging does this patient have in terms of cardiogenic shock?
00:09:49
Speaker
So the sky classification is one that is most likely, you know, most of us are using.
00:09:55
Speaker
And basically this, the Society of Cardiovascular Angiography and Interventions came up with, there's five stages of shock.
00:10:02
Speaker
There's A, B, C, D, E. E is what you and I as intensivists, we see it without even going into the room, right?
00:10:10
Speaker
We look at that base excess.
00:10:12
Speaker
We look at that bicarbonate.
00:10:13
Speaker
We look at before we even get the lactate with the physical examination.
00:10:17
Speaker
You know this is a patient that is an extremist.
00:10:22
Speaker
But what does that look like?
00:10:23
Speaker
That's a patient that is stage E, is hypotensive.
00:10:27
Speaker
The patient is on maximal support.
00:10:29
Speaker
The patient is about to have a rest and they're in full-on shock extremist.
00:10:34
Speaker
And the next stage before that is stage D. And that's the, you know, deteriorating phase and the stages of doom, right?
00:10:43
Speaker
And that's a patient that basically is actively deteriorating, requiring multiple pressors, or you are actually on mechanical circulatory support to maintain the perfusion.
Timing and Implementation of MCS
00:10:53
Speaker
The stage before that is stage C. And if you notice, I'm going backwards because we are intensivists.
00:11:00
Speaker
The only way to get attention is you go from E to back.
00:11:03
Speaker
And stage C is the patient that you walked into in the morning and you got that feel that like, hey, let me get some things right.
00:11:11
Speaker
But the stage C hemodynamic profiling and understanding of that is incumbent upon our intensivist really getting the SWAN in place and getting that SWAN plus ECHO plus the physical exam and all of that together.
00:11:28
Speaker
So if your systolic blood pressure is low, your perfusion is low, and the other thing is, you know, your index is dropping, it's less than 2.2, your wedge pressure is elevated, that's the number 15.
00:11:39
Speaker
Your right atrial pressure to the wedge pressure ratio, right?
00:11:43
Speaker
So that's like a easy, crude way of saying what's coming into the pump is not being squeezed out of the right ventricle.
00:11:50
Speaker
So that ratio...
00:11:52
Speaker
If that is more than 0.8 and then pulmonary artery pulsatility index, that's basically, you know, a crude way of also saying is like is the right ventricle working and that's PA systolic minus diastolic divided by CVP.
00:12:07
Speaker
You will see about 2,000 papers on this, but basically each that PAPI is validated to be low in each different disease states.
00:12:16
Speaker
For instance, if you have a patient with PAH, the PAPI number that differentiates what is crude RV failure is different than patient with post-LVADR.
00:12:26
Speaker
So for sky classification for your states, the classic, you know, this is a patient that's really going into cardiogenic shock and we want to take care of the PAPI number is less than 1.85.
00:12:40
Speaker
So then you go, okay, that's great.
00:12:42
Speaker
But what do you look for in the labs and biochemical markers that remember that hemodynamic problem going into hemometabolic problem?
00:12:49
Speaker
That's where we are looking at the lactate levels.
00:12:52
Speaker
your creatinine levels, your LFTs and your BNP that is rising.
00:12:56
Speaker
And I think at the bedside, all you have to do is open the sheets and touch their feet, right?
00:13:02
Speaker
They tell you a lot about the perfusion of the patient.
00:13:05
Speaker
And then stage B is your systolic is low, your MAP is less than 60, pulse is more than 100, your index is still more than 2.2, your renal function lactate, all of the more preserved, B and P is elevated.
00:13:18
Speaker
And this patient may or may not have entered your ICU yet, right?
00:13:23
Speaker
And then stage A is a patient that is at risk.
00:13:27
Speaker
So when you put this together, so you have a methodology and you say, okay, I have a patient with cardiogenic shock.
00:13:35
Speaker
I have this kind of profile.
00:13:37
Speaker
And then you say, how do I know that somebody needs to be augmented with temporary MCS?
00:13:45
Speaker
To know why we need to do that, we already know that the mortality is high, that's great.
00:13:50
Speaker
But what is it that actually happens that causes this mortality, right?
00:13:54
Speaker
We know that once it becomes a hemometabolic problem, lactate is going up, then the pulse pressure is narrowing, and then you have a PEA that will happen, right?
00:14:03
Speaker
But that's, I think, for me, that's the high-hanging fruit.
00:14:08
Speaker
Obviously, we want to save lives, but that thinking has not helped us.
00:14:13
Speaker
Because we all knew that like that was going to happen, but the mortality still remains high.
00:14:19
Speaker
The mortality remains high wherever, right?
00:14:20
Speaker
Like, you know, they have fantastic, it's like COVID.
00:14:23
Speaker
Yes, you came to a COVID ECMO center, your mortality was still high, right?
00:14:29
Speaker
Because the reason is it's like minutes matter.
00:14:31
Speaker
It's when you put in the MCS also matters.
00:14:34
Speaker
And that when is incumbent upon the shockologist, which is you.
00:14:39
Speaker
Because you have that premonition based on either your training or your ears at the bedside or simply your intellectual understanding of how the human body works and you can see it before it happens.
00:14:53
Speaker
And what is about to happen, because I think we know a coding patient is sick, but that's too late.
00:15:00
Speaker
So we need to really dive into our resources and
00:15:04
Speaker
in that stage C to stage D as intensive as and rapidly escalate.
00:15:10
Speaker
I'm not talking about MCS, guys.
00:15:12
Speaker
I'm talking about getting them into the ICU, floating a swan, really understanding mixed venous, really trying to phenotype, okay, what's the problem?
00:15:20
Speaker
Where is the problem, right?
00:15:21
Speaker
If we don't do it, you're going to have refractory arrhythmias, and then you're going to have that intractable VT, and now you're stage E and pulling them back is going to be much harder, right?
00:15:34
Speaker
So in the timing aspect of MCS is where we as intensivists, I think, play the highest role.
00:15:45
Speaker
I know how privileged I am.
00:15:48
Speaker
I absolutely know that.
00:15:49
Speaker
I recognize the privilege and hence I'm here.
00:15:52
Speaker
I know that I get to sit here with all the devices and all these intensivists that are supported by advanced short failure MCS guys,
00:16:01
Speaker
The MCS surgeons, the perfusionists, the amazing nurses.
00:16:05
Speaker
But I'm here to tell you that even these patients in our unit sometimes don't make it because the patients come to us far too late.
00:16:14
Speaker
It's a STEMI that has burnt out the wall of the ventricle, right?
00:16:19
Speaker
Like, yes, we can decompress, but it would have been much nicer had we not gotten to this point.
00:16:25
Speaker
And then so we know how STEMI minutes matter, but the cardiogenic shock minutes matter is just this evolving paradigm with cardiogenic shock teams.
00:16:35
Speaker
So you all have to be able to, at the bedside, figure out, is this an RV dominant shock?
00:16:42
Speaker
Is this a by V shock?
00:16:44
Speaker
Is this an LV dominant shock?
00:16:45
Speaker
Because your management then kind of dictates what type of MCS can you advocate for this patient?
00:16:54
Speaker
So, so far we went over the sky classification and what is classic C, D and E, and we focused on let's go full blown into D and E, right?
00:17:03
Speaker
Like let's really figure out that C, D so we don't get to an E. Now, what are these profiles in cardiogenic shock?
Exploring Different MCS Devices
00:17:14
Speaker
One crude way that I've taught over the years in the MCS unit is I look at the human body as a series of test tubes.
00:17:23
Speaker
We get blood into the right atrium.
00:17:25
Speaker
Right atrium puts blood into the right ventricle, then in the PA, then into the lungs, then into the LA, then the LV and the aorta.
00:17:32
Speaker
So if we had a swan and we had these numbers, you just kind of write it out.
00:17:37
Speaker
What are my numbers saying?
00:17:39
Speaker
Let's just say, for example, my CVP is 20, okay?
00:17:44
Speaker
And then my PA pressure is elevated.
00:17:48
Speaker
Then in the left atrium, my wedge pressure is like 10, okay?
00:17:53
Speaker
right and the chest x-ray does not show any pulmonary edema so then you already know that the blood is going into the right atrium it's going in through the pulmonary artery so there's no obstruction there so the rv is trying to do its job but there is no way that this blood is going back into the left atrium and you know that there is no pulmonary edema so more than likely this is severe pulmonary hypertension
00:18:18
Speaker
Now, why does that matter for cardiogenic shock?
00:18:21
Speaker
Because if you go and put in a balloon in this patient, it ain't going to work, right?
00:18:25
Speaker
The blood actually needs to enter the left atrium.
00:18:27
Speaker
So you may want to do some inhaled nitric oxide, squeeze the ventricle a little bit, do some pulmonary vasodilation or call one of us that do pulmonary arterial hypertension therapies and go, hey, can you phenotype this patient?
00:18:41
Speaker
Is this PAH?
00:18:42
Speaker
Can you start the therapist, right?
00:18:44
Speaker
Now, similarly, let's take the same patient.
00:18:47
Speaker
CVP is elevated, right ventricle is filled.
00:18:49
Speaker
You saw the echo.
00:18:51
Speaker
You're focus trained.
00:18:53
Speaker
You looked at the TAPC and you're like, dude, this ventricle ain't moving.
00:18:57
Speaker
Then you looked at the pulmonary artery.
00:18:59
Speaker
Again, pressures are elevated.
00:19:01
Speaker
Then you did the wedge pressure.
00:19:03
Speaker
And if your wedge pressure is 20, let's say, and your CVP, I'm going to just give you a big number, 25.
00:19:11
Speaker
hey, you know, this is not working.
00:19:14
Speaker
This patient not only has RV, it looks like, you know, and then you look at the LV on echo and you look at an LVEDP, that's also elevated.
00:19:23
Speaker
You're like, oh, this is a patient in Bi-V shock.
00:19:26
Speaker
And that's the most common kind that you're going to see other than because the LV ones are probably already in the CCU.
00:19:33
Speaker
But the Bi-V ones can mess with you.
00:19:36
Speaker
They're going to have kidney.
00:19:38
Speaker
They're going to have a creatinine that is elevated.
00:19:40
Speaker
They are going to have ascites.
00:19:41
Speaker
They are going to look like, okay, this person is clearly septic, right?
00:19:46
Speaker
And then you're like, okay, that's great that we come up to diagnosis of sepsis, but why is my CBP like 25?
00:19:52
Speaker
This is distributive shock, right?
00:19:56
Speaker
Then you're like, okay, so CVP elevated, wedge pressure elevated, CVP over wedge pressure ratio is elevated.
00:20:03
Speaker
And then you say, if my pulmonary artery pulsatility index is also low, right, that's a BIV shock.
00:20:11
Speaker
What about a patient with LV dominant shock?
00:20:13
Speaker
Now, this person usually is pretty straightforward.
00:20:19
Speaker
Your CVP is low.
00:20:21
Speaker
It may be less than like classic, like, you know, 14%.
00:20:29
Speaker
Your CVP to wedge pressure ratio may be less than 0.86, and your papi may be preserved.
00:20:35
Speaker
Now, that's a beautiful case of LV dominant shock.
00:20:39
Speaker
Now, if you take a patient with LV dominant shock and he's in your ICU and the blood pressure is low, you add some levo, you add some vaso, of course the blood pressure is going to increase, right?
00:20:51
Speaker
Right.
00:20:51
Speaker
But that patient at the end of the day, that LVDP in front of you is going up.
00:20:58
Speaker
And you know, let's assume that this is an AMI shock.
00:21:01
Speaker
In front of you, this balloon that we call the left ventricle is increasing, is increasing, right?
00:21:07
Speaker
And then you have the mechanical complications of AMI.
00:21:10
Speaker
Whether it is your mitral regurgitation, whether it is VSD and in worst case, the free wall ruptures, right?
00:21:16
Speaker
And there's nothing you can do.
00:21:17
Speaker
Yeah, you give pressers, but those were not adequate because the pressers can only go so far.
00:21:23
Speaker
What that patient really needed, ideally was already she had gone to the cath lab.
00:21:27
Speaker
But then that is a patient that you started inotropic support and it was not quite working.
00:21:34
Speaker
And you decided that that's a patient that I may need temporary MCS on.
00:21:39
Speaker
Right.
00:21:39
Speaker
And that's when going into the question that Sergio is asking is,
00:21:45
Speaker
tell us about temporary MCS.
00:21:47
Speaker
And so we can't talk about temporary MCS until we get these alphabets done.
00:21:51
Speaker
So we're done, now let's go into the words.
00:21:54
Speaker
And that's when we go into what are the kinds of temporary mechanical circulatory support devices available.
00:22:02
Speaker
Sergio, is that a good starting point for us?
00:22:07
Speaker
So we talked about the sky classification.
Patient Pathways and Heart Team Approach
00:22:10
Speaker
I think the indications are very important to emphasize the importance of time-sensitive interventions, right, and how time really has a tremendous implication on final patient outcomes.
00:22:23
Speaker
And let's review now.
00:22:25
Speaker
Once we made a decision that our patient is in shock, we, as you explained, have looked into the phenotype, have classified as best we can, and are feeling that our patient is going to need more support.
00:22:37
Speaker
What are the options we have today in terms of temporary support for that patient?
00:22:43
Speaker
So there are many, I mean, you know, you can just Google temporary MCS and you'll see everything.
00:22:50
Speaker
But I want you guys to go back to your algorithm and separate it now into, am I dealing with an RV failure patient?
00:23:02
Speaker
Am I dealing with a by V patient?
00:23:04
Speaker
Or am I dealing with an LV failure?
00:23:06
Speaker
First of all, just, you know, and now we have shock extremists, right?
00:23:12
Speaker
out of all of these in your ICU, in a patient that is about to code or is coding, the number one device that you need to know about is the Veno Arterial ECMO, right?
00:23:29
Speaker
It can be placed in the intensive care unit.
00:23:32
Speaker
You can just drop in five French sheets in the artery and the vein to get the patient ready for cannulation.
00:23:40
Speaker
The patient can be immediately supported.
00:23:42
Speaker
It takes blood from the vein.
00:23:45
Speaker
So if your drainage cannula is all the way up in SVC, it drains from the SVC and IVC.
00:23:51
Speaker
If your drainage cannula from the femoral is just in the IVC, then it's draining from the IVC, taken to a pump, right, a centrifugal pump, pushed through a membrane or an oxygenator into the femoral artery back in through the aorta.
00:24:10
Speaker
This will enable you to provide temporary perfusion in the setting of complete cardiopulmonary failure.
00:24:20
Speaker
So in shock extremist, the first device is VA ECMO.
00:24:25
Speaker
The way we know arterial ECMO works is obviously it's your classic cardiopulmonary bypass that you would do in the operating room.
00:24:35
Speaker
It's typically the return cannulas, which is going into the aorta or about 15 to 22.
00:24:41
Speaker
And the drainage cannulas can go up and, you know, the cannula sizes go.
00:24:47
Speaker
It differed depending upon the body habitus of the patients, 18 to 21.
00:24:53
Speaker
Now, what are the advantages?
00:24:55
Speaker
It has a membrane, right?
00:24:56
Speaker
So if a patient is also having hypoxemia or along with other etiologies such as PE and stuff, you know, you're able to oxygenate the patient.
00:25:07
Speaker
The second thing that I need you to know about Vino-RTG-LECMO
00:25:14
Speaker
the one that is done in the ICU, as from intensivist perspective, is if patients have peripheral arterial disease, imagine putting in a complete obstructing cannula in the femoral artery, right?
00:25:27
Speaker
That leg will become ischemic.
00:25:29
Speaker
So you typically put in another small catheter to perfuse the distal leg.
00:25:35
Speaker
The reason I'm telling you all about it is if you are...
00:25:38
Speaker
If you're part of a hub-and-spoke model, the patient is cannulated and they're about to take the patient, you need to watch these legs to make sure they don't get ischemic.
00:25:50
Speaker
What are the disadvantages of veno arterial ECMO?
00:25:54
Speaker
We just talked to you about limb ischemia.
00:25:56
Speaker
Of course, they'll need anticoagulation.
00:25:57
Speaker
So, you know, all of the everything that can happen does happen, will happen the more you do, just like in ICU, right?
00:26:05
Speaker
Right.
00:26:07
Speaker
Now, who are the patients you can do it in?
00:26:10
Speaker
If the patient has severe aortic insufficiency or if the patient truly has sepsis and distributive etiology, no amount of three liters flow is going to be able to augment that patient, right?
00:26:21
Speaker
It's just it's not enough three to four liters.
00:26:24
Speaker
Sometimes, you know, central ECMO can give you all the way up to 30.
00:26:28
Speaker
six, seven, if you can, depending upon the cannulas, but peripheral, like most, you know, they write four to 10 liters sometimes support, but maybe maximum, like, you know, we, we've the bedside 4.85.
00:26:40
Speaker
With the sweep gas, we can remove the CO2 and add oxygen, right?
00:26:47
Speaker
The sweep gas can go up.
00:26:49
Speaker
And if you have significant dead space that can help.
00:26:52
Speaker
So your VA ECMO can help you in RV failure, in BIV failure, and in LV failure, meaning if a patient is coding.
00:27:03
Speaker
But the minute that you put these patients on VA ECMO, you wait for the shock extremist to kind of die down.
00:27:16
Speaker
Is it just RV, meaning the lungs are okay?
00:27:19
Speaker
We don't really need an oxygenator.
00:27:21
Speaker
We don't really need this cannula in the aorta.
00:27:24
Speaker
Then you need to ask yourself, yeah, VA ECMO is a great right ventricular assist device because it's suctioning blood right out of the vein, right?
00:27:33
Speaker
But anything you can do to de-escalate or downsize into a smaller, more sophisticated, you can do.
00:27:41
Speaker
The same thing is for LV failure.
00:27:47
Speaker
is on Veno-Arterial ECMO.
00:27:48
Speaker
And, you know, when the New England Journal trial came out, it's like VA ECMO in cardiogenic shock, there is not significant help.
00:27:56
Speaker
We were like, of course, we know that.
00:27:57
Speaker
Like it was only supposed to help when the patient is like deathly ill and dying, and then you're supposed to change it over.
00:28:04
Speaker
What do I mean by that?
00:28:06
Speaker
If you remember back when
00:28:08
Speaker
When I say back, back, back, back into med school with the PV loops, I know you guys do our PV loops really well with the lung, with ARDS, right?
00:28:20
Speaker
But the PV loop of the heart, where you can see in cardiogenic shock, right, the PV loop moves to the right.
00:28:32
Speaker
Your end diastolic volume is going up, your blood pressure is coming down, it moves to the right.
00:28:39
Speaker
In VA ECMO, it doesn't bring it back to the left.
00:28:43
Speaker
It moves it even more to the right.
00:28:46
Speaker
So think of like, you know, in ARDS, how the limb becomes flattened and then, you know, your entire loop is getting, you know, wider and wider.
00:28:55
Speaker
So in the cardiac loops with VA ECMO, the endostolic, right, your LV is actually having to work harder because you have a hose in the aorta.
00:29:08
Speaker
So what you want to do in these settings is you support the patient, of course, you know, work with your cardiology colleagues and you say, okay, so I have a patient, I immediately supported them, but now I have it, this is AMI cardiogenic shock.
00:29:25
Speaker
So you've taken them to the cath lab, you worked on the culprit lesion, and then you say, where is my problem?
00:29:31
Speaker
So let's look at the test tube method, right?
00:29:34
Speaker
So right atrial pressure is up, RV pressure is up, PA is up, LA is up, LV is up, LVEDP is up, but the aorta, the mean arterial pressure is low because your LV is big, right?
00:29:47
Speaker
So all you have done with VA ECMO is you bypass from the right atrium to aorta bypass.
00:29:53
Speaker
This LV is not being unloaded.
00:29:56
Speaker
If anything, there's a possibility that you may be harming it.
00:30:00
Speaker
It's incomplete LV unloading.
00:30:02
Speaker
So you have to figure out
00:30:06
Speaker
Right now, your temporary support devices, if you have isolated LV, you can put this patient on the impeller support system where it takes blood from the left ventricle and puts it over the aortic valve.
00:30:26
Speaker
Right here, left ventricle suctioning blood through the pigtail catheter and putting it over the aortic valve.
00:30:32
Speaker
So it's an LV aorta bypass, whereas a VA ECMO was what?
00:30:36
Speaker
Right atrial aorta bypass, right?
00:30:39
Speaker
So you are really addressing it where the problem is with the impeller.
00:30:45
Speaker
So a typical scenario may look like this.
00:30:48
Speaker
Patient is in shock E. You astutely call your team.
00:30:53
Speaker
The patient was put on VA ECMO.
00:30:56
Speaker
You again see that, okay, the VA ECMO is put in, but now the patient's LV is getting bigger.
00:31:03
Speaker
Their pulsatility, pulsatility is their systolic divided by diastolic, is very small.
00:31:09
Speaker
Let's say it's less than 10, then it's not unloading.
00:31:12
Speaker
You put a echo probe on and there's smoke in the ventricle.
00:31:16
Speaker
And they're not ejecting.
00:31:17
Speaker
Yes, they're on anticoagulation.
00:31:19
Speaker
You're like, hey, you know, we need to, because you want to preserve muscle function, then you want to vent the ventricle.
00:31:27
Speaker
You surgically as well, there's like an LV sump that the surgeons can put in.
00:31:31
Speaker
It's not, it impella, it's just the current available percutaneous approach, right?
00:31:37
Speaker
So you unload and then you say, hey, my lungs are fine.
00:31:41
Speaker
I've unloaded it.
00:31:43
Speaker
Do I really need the veno arterial ECMO?
00:31:45
Speaker
Then you come down on the veno arterial ECMO, the flow, and you see you maintain the blood pressure over the next two, three days.
00:31:52
Speaker
It looks like the pressure is being maintained.
00:31:54
Speaker
The patient is ejecting well, then you can decannulate that person.
00:31:58
Speaker
Now you've taken an AMI cardiogenic shock.
00:32:01
Speaker
with low index in shock extremists supported them on VA ECMO plus impeller then changed it over from an acpella like ecmo plus impeller to just an impeller device as let's say a bridge to recovery that's called btr bridge to recovery the other wording that is used is bridge to decision so you're trying to figure out btd
00:32:27
Speaker
And the other thing people use is bridge to transplant or bridge to LVAD.
00:32:34
Speaker
Either way, the problem that I need you to recognize is it's not just supporting the patient, timely support.
00:32:43
Speaker
It's at the same time, parallelly thinking, where am I taking this
Exit Strategies for MCS Patients
00:32:48
Speaker
patient?
00:32:48
Speaker
How do I get this patient home?
00:32:53
Speaker
I think, Bindu, you made a very important point in terms of whenever you start somebody on mechanically circular support, you're thinking of your exit strategy, right?
00:33:01
Speaker
And you talked about bridge to transplant.
00:33:04
Speaker
Not everybody's a candidate for transplant, obviously.
00:33:06
Speaker
You talked about bridge to recovery, which is those patients who we think have a decent chance or a chance to recover.
00:33:13
Speaker
But you also mentioned
00:33:15
Speaker
the bridge to decision, which is something a lot of intensivists, I think, don't always appreciate, that sometimes it's unclear what the trajectory will be or should be, and the buying time to make that decision of what the next step is can also be very powerful.
00:33:30
Speaker
Could you comment on that a little bit?
00:33:32
Speaker
Yeah, I think this is when the intensivists actually have the most crucial goals
00:33:46
Speaker
player status when you work in a large team called the heart team approach.
00:33:54
Speaker
You have already stabilized, you put in your groundwork, just like the interventional cardiologist that did the plumbing and that tried to see and that put in the patient with the MCS or the surgeon.
00:34:05
Speaker
You as the intensivist are able to talk to the family, you bridge that connection and
00:34:11
Speaker
And I think one of the things that I've noticed is the same working understanding of recognizing which septic patients won't make it.
00:34:29
Speaker
We tend to apply that to the heart failure patients.
00:34:34
Speaker
And I am going to argue that I,
00:34:38
Speaker
Even though you may be right, I mean, only trials will have to show this, I would argue that in a developing field such as mechanical circulatory support, you cannot tell me that this guy that was admitted five times for heart failure that now has come in is on temporary MCS should proceed to either withdrawal of care or comfort care because studies have shown when you are admitted this many times, these patients' mortality is high.
00:35:05
Speaker
Yeah, well...
00:35:06
Speaker
Studies have also shown that heart failure patients that keep going home will die.
00:35:10
Speaker
They should have been supported and taken from stage C and referred to a durable LVAD program sooner too.
00:35:17
Speaker
Do you see that?
00:35:19
Speaker
So I am asking you, or rather persuading you, to think of it as you know 30% of cardiogenic shock
00:35:33
Speaker
The other 70%, the chapters are being written, and I am going to stay here and say, the more the intensivists can escalate at a faster rate, the mortality will only improve for the patients with temporary MCS, and in which case, the survival over the next 10, 20 years will improve.
00:35:57
Speaker
So,
00:35:58
Speaker
don't need to think of every patient and go, well, I don't want to offer ECMO because this guy is not going to get transplant.
00:36:06
Speaker
I want you to look at it as what are the terminal conditions the patient has?
00:36:11
Speaker
Okay, if the patient has leukemia, lymphoma, metastatic cancer, advanced elderly age that is non-functioning, all of those, of course, those are the easy buckets.
00:36:23
Speaker
Then the pristine candidates are the easy bucket as well, right?
00:36:26
Speaker
Like 28-year-old comes in peripartum cardiomyopathy, is in state of shock.
00:36:31
Speaker
Boom, like everything, right?
00:36:33
Speaker
Everything.
00:36:33
Speaker
We do everything and we do it well.
00:36:36
Speaker
It's the gray bucket.
00:36:37
Speaker
The 66-year-old that has come in and out of the hospital, has mild AKI, was a smoker up to like five years ago.
00:36:47
Speaker
I just humbly ask that you don't take that burden on you.
00:36:52
Speaker
You reach, at least if you're an institution that offers hard programs, then you're probably not, like you're doing this already, but share the burden.
00:37:03
Speaker
Sharing the burden enables you to consider alternative viewpoints.
00:37:10
Speaker
So for instance, Sergio, brief, brief, very brief exit, durable LVAD.
00:37:19
Speaker
In the early 2000s, the rematch trial came.
00:37:23
Speaker
The rematch trial showed that in patients that are not transplant candidates, the optimal medical management group, and remember this, you know, save and solve trials and all those trials were out.
00:37:35
Speaker
We were on ACE inhibitors.
00:37:36
Speaker
We were on diuretics, right?
00:37:40
Speaker
Then that trial showed, despite optimal medical management, the survival was only 8%.
00:37:49
Speaker
8%, guys.
00:37:53
Speaker
And the survival went to 24% at two years with the first generation LVADs.
00:38:03
Speaker
And this one was barely, I mean, you know, in terms of the number of patients, right?
00:38:09
Speaker
It was not that many.
00:38:11
Speaker
It was like 68 and 61.
00:38:14
Speaker
That trial really started the LVAD.
00:38:18
Speaker
programs everywhere.
00:38:21
Speaker
So right now, optimal medical management, maybe these weight loss medications will change that curve, has improved from 8% at two years with this life-saving, billion-dollar industry and everything, right?
00:38:38
Speaker
Has improved.
00:38:39
Speaker
But I ask this one of my favorite questions I ask our fellows,
00:38:44
Speaker
They're like, oh, it's 70%.
00:38:46
Speaker
I'm like, try like, you know, try 24, 30, maybe like in the best of hands, like maybe a little bit higher.
00:38:54
Speaker
So optimal medical management in end-stage heart failure has a long way to go.
00:38:59
Speaker
So who are you and I at the bedside in just one passing, this guy is never going to get a durable LVAD.
00:39:06
Speaker
We have to try the bridge to recovery.
00:39:09
Speaker
We have to try or at least give due justice for bridge to decision.
00:39:14
Speaker
And at the very least, take this hemodynamic, hemometabolic problem, support them in ideal situations, and at least bring it back to where you can say, I just have this problem and I'm going to try to see and then have a very tight ballgame, like in X number of weeks or X number of days, if this doesn't work, we have nothing else.
00:39:36
Speaker
And that you can only really do with a heart team approach.
00:39:39
Speaker
So that's for LV failure.
Advanced MCS Devices: Use and Management
00:39:41
Speaker
So you really want to be able to say, I want to have an exit.
00:39:48
Speaker
I really want to be able to support them.
00:39:50
Speaker
So we talked about the impeller.
00:39:52
Speaker
We talked about VA ECMO.
00:39:55
Speaker
intra-aortic balloon pump.
00:39:57
Speaker
And I think you know that this is the most commonly used counter-pulsation device.
00:40:02
Speaker
It sits nicely in the descending aorta and it improves coronary perfusion and cardiac output.
00:40:11
Speaker
There are
00:40:12
Speaker
There's some data whether it actually augments cardiac output or not.
00:40:17
Speaker
But, you know, for you, literally in most of the ICUs, IABP is available.
00:40:24
Speaker
I want you to think about it as augmenting systemic perfusion and some coronary perfusion.
00:40:30
Speaker
It's very easy.
00:40:32
Speaker
Everyone knows how to do it.
00:40:34
Speaker
And I think that's a simple enough thing.
00:40:37
Speaker
And I advise my shockologists, you all,
00:40:41
Speaker
Next time the patient is on balloon pump, look at the waveforms.
00:40:46
Speaker
There are so many resources online to learn the waveforms.
00:40:50
Speaker
And I think if you're a student, which you are, that's the reason you're listening right now.
00:40:55
Speaker
You will really, it's physiologically, it makes sense, right?
00:40:59
Speaker
Dicrotic notch, it augments, then, you know, what happens to SPP.
00:41:05
Speaker
Now, what is the third device?
00:41:07
Speaker
So balloon pump, I'm just saying, you know, you guys know it.
00:41:11
Speaker
ECMO, we talked.
00:41:12
Speaker
Impella, we talked.
00:41:13
Speaker
Now, Impella, there's two, right?
00:41:15
Speaker
There's the Impella CP, and then there's the Impella.
00:41:19
Speaker
Right now, we use the 5.5.
00:41:21
Speaker
What is the main difference?
00:41:23
Speaker
The Impella CP is emergently usually placed in the cath lab, and it provides support, but it's a much smaller amount of support compared to the bigger 5.5.
00:41:36
Speaker
So the 5-5 needs a surgical cut down, axillary graft, but if the patients for some reason don't have a good upper extremity anatomy, it can be also suited stratically into the aorta.
00:41:49
Speaker
Surgeons are able to place it.
00:41:51
Speaker
then these patients experience direct ventricular unloading.
00:41:55
Speaker
They do need anticoagulation.
00:41:57
Speaker
Limb ischemia can happen.
00:42:00
Speaker
And sometimes aortic valve can be damaged.
00:42:06
Speaker
But the most important thing is these patients, especially with the upper extremity one,
00:42:12
Speaker
They come out, they're supported, you can extubate them, you're walking them.
00:42:16
Speaker
And it's a good bridge to decision device because you can see, because, you know, if you're supporting them four to five liters of decompression, that's essentially a trial run of a durable LVAD, right?
00:42:27
Speaker
You're like, I'm going to support them, I'm going to decompress them, I'm going to see.
00:42:31
Speaker
If their multi-organ failure is going to get better, I'm going to see if their cacaxia is going to improve.
00:42:36
Speaker
I'm going to see if they're going to declare themselves, meaning like are they going to be good candidates, or maybe it's a bridge to recovery.
00:42:44
Speaker
Their AMI cardiogenic shock is improving, and then I'm going to be able to recover them.
00:42:50
Speaker
Again, it takes a sophisticated unit to know the nuances.
00:42:56
Speaker
I think a big part, and Sergio, I think you probably can attest to it.
00:43:02
Speaker
It's not about getting it right in ICU medicine that you and I are here.
00:43:07
Speaker
It's trying to not get it wrong, right?
00:43:08
Speaker
Right.
00:43:09
Speaker
So the more experience you have, the better you're going to be.
00:43:12
Speaker
And you also see that not all patients need impeller support.
00:43:16
Speaker
There are some patients, maybe you should have removed the impeller and the patients are recovering.
00:43:20
Speaker
And I think those are the nuances that you can learn at the bedside as you take care of these patients and with additional training too.
00:43:28
Speaker
Now, what is the entire tandem part, right?
00:43:33
Speaker
I'm going to, so Levanova pulled the pump, but I think the cannulas are available, but I'm going to tell you, let's say the same test tube method.
00:43:42
Speaker
Right atrium is up, right ventricle is up, PA pressures are up, LA pressures are up, lungs are flooded.
00:43:50
Speaker
But then you go to an LVEDP and the LVEDP is low.
00:43:54
Speaker
So this patient, let's say, has
00:43:57
Speaker
giant left atrial syndrome, severe mitral stenosis.
00:44:01
Speaker
You put in a patient, you put the VA ECMO on for temporary, they're crashing, but you didn't solve the problem, right?
00:44:08
Speaker
Can you put in an impeller?
00:44:10
Speaker
Can you, will that help?
00:44:12
Speaker
If the blood is not coming from the left atrium to the left ventricle, putting in an impeller won't help either, right?
00:44:19
Speaker
patient, what do you really need?
00:44:21
Speaker
You need the left atrial bypass, right?
00:44:23
Speaker
Left atrium, blood needs to be sucked and put it into the aorta.
00:44:28
Speaker
So the tandem cannula and Dr. Carr's group, Texas Heart, one of the best publications.
00:44:35
Speaker
And I'm so proud to be in this team.
00:44:37
Speaker
And I was witness to this as, you know, young faculty, like patients, you know, like he would put it on coding patients with the team.
00:44:45
Speaker
And I'm just like completely marveled at this.
00:44:48
Speaker
You take the venous, like you access venous side, you access the arterial, just like you're doing a VA ECMO.
00:44:54
Speaker
But your drainage cannula, under floral, you're going into the right atrium from the IVC and you're transversing the PFO, making it big, creating an atrial septostomy and you're suctioning blood from the left atrium.
00:45:15
Speaker
into the aorta.
00:45:17
Speaker
Since you're doing deoxygenated blood from the left atrium, with the VA ECMO, it's deoxygenator, so you put in an oxygenator.
00:45:25
Speaker
But with the tandem, since you're removing it from the left atrium, which is already oxygenated, into the aorta, you don't need an oxygenator.
00:45:33
Speaker
So that's what a tandem heart is.
00:45:37
Speaker
So tandem heart again, LV, you know, can you use it in LV, like just straight LV failure?
00:45:44
Speaker
Yeah, because, you know, blood comes from the left atrium to the left ventricle and causes LV ETPs go up, right?
00:45:50
Speaker
Like why not just suction it from the left atrium directly?
00:45:53
Speaker
Mitral stenosis, your classic LV failure.
00:45:56
Speaker
What are the reasons, what are some of the issues with it?
00:46:02
Speaker
In ICU, we took care of a lot of tandems.
00:46:05
Speaker
In the ICU, the patients are immobile, right?
00:46:08
Speaker
They're like, they're immobile.
00:46:13
Speaker
Cardiac perforation in like, you know, inexperienced hands or the patients, you know, it's a, any device carries with it risks.
00:46:22
Speaker
And then the other thing is when a patient is put on tandem heart and you're taking it out and the patient, let's say, has improved, now you've created a hole, right?
00:46:33
Speaker
So they have a residual ASD.
00:46:36
Speaker
So sometimes you have to go and close it.
00:46:38
Speaker
The most important thing to know as intensive is if you're taking care of a tandem patient is the patients are immobile compared to your other devices because it's going against the PFO, across the PFO, the cannula may migrate.
00:46:54
Speaker
There's another thing called the lava.
00:46:58
Speaker
Basically, the cannula can drain from the left atrium and the right atrium via ECMO.
00:47:06
Speaker
So this way you're decompressing the left side and, you know, you're immediately stabilizing.
00:47:12
Speaker
Again, you need to put, you know, patients need to be in the cath lab because you're putting the cannula under floral.
00:47:18
Speaker
So that's the last in terms of temporary MCS for left side.
00:47:24
Speaker
Very quickly, I'll touch upon the right side.
00:47:29
Speaker
A frequent question is, hey, why can't we put an R-VAD in patients with, for instance, severe pH?
00:47:37
Speaker
See, severe pH, yes, you can put in an R-VAD if the patient had severe pH and just something happened and the patient got pushed over.
00:47:47
Speaker
But at the end of the day, the resistance is high.
00:47:49
Speaker
So you're just giving a bypass from RA to PA.
00:47:54
Speaker
What you really need is that blood to go from the PA to the LA, right?
00:47:59
Speaker
So that's the reason RVADs typically don't help and you really need those powerful pulmonary vasodilators.
00:48:05
Speaker
But what if the patient has an RCA infarct?
00:48:09
Speaker
Then yeah, you know, RAPA bypass.
00:48:13
Speaker
Right now, you know, there's in terms of the cannulas, there are multiple like the tandem RVAD, the RPFLEX,
00:48:28
Speaker
Where else can you use them?
00:48:30
Speaker
Post-LVAD RV failure.
00:48:32
Speaker
Anything that causes an isolated RV issue, you can think about.
00:48:37
Speaker
And they work the same way.
00:48:38
Speaker
I just want you to think that they work the same way.
00:48:42
Speaker
Now, is there any other classification when people start talking about that I can share with you?
Book Recommendation: 'The Alchemist'
00:48:50
Speaker
One clinical pearl is
00:48:54
Speaker
anything before the hyphen is drainage and anything after the hyphen is returned.
00:49:00
Speaker
And drainage is always to the pump, meaning I am taking blood from the vein to the pump.
00:49:06
Speaker
So it's V-A, I'm returning it to the artery.
00:49:11
Speaker
So it's pump focused.
00:49:13
Speaker
If I take it from two veins and give it to the artery, it becomes V-V-A.
00:49:19
Speaker
If I take it from two veins and give it to an artery and a vein, then it becomes VV-AV.
00:49:24
Speaker
Okay, that's one technology.
00:49:26
Speaker
I want you to know the nomenclature.
00:49:29
Speaker
The second nomenclature to really know is, is it an axial or is it a centrifugal?
00:49:36
Speaker
For instance, a VA ECMO, the pump is outside.
00:49:38
Speaker
It's a centrifugal pump.
00:49:40
Speaker
Whereas an impeller, an axial flow is intracorporeal.
00:49:44
Speaker
That's an axial flow inside the body.
00:49:48
Speaker
ECMO?
00:49:49
Speaker
extracorporeal.
00:49:50
Speaker
So know the hyphen method, know if you're dealing with a pump that is intracorporeal or extracorporeal inside the body, outside, and then know is it an axial flow, centrifugal flow.
00:50:06
Speaker
At least as you follow your patients that go on to temporary MCS,
00:50:11
Speaker
then you can look at it and go, hey, you know, I understand.
00:50:15
Speaker
I understand the classification, where they get it.
00:50:18
Speaker
How do you separate a univentricular, biventricular failure patient?
00:50:22
Speaker
What are all the MCSs that are available right now?
00:50:26
Speaker
And be able to draw it out for yourself.
00:50:29
Speaker
You would be surprised.
00:50:31
Speaker
You know, you can say, why can't this help?
00:50:33
Speaker
Tell me why it doesn't help.
00:50:36
Speaker
And I think you talk it out and go from there.
00:50:42
Speaker
Sergio, I know we touched base about Sky and then the kinds of devices and then supporting devices right and left.
00:50:53
Speaker
briefly about PV loop.
00:50:55
Speaker
I mean, I'll have to come back on your podcast, man, if you want me to do everything.
00:51:01
Speaker
So for sure.
00:51:01
Speaker
And I think that definitely we have a part two scheduled where we'll talk more about the specific management, including troubleshooting,
00:51:11
Speaker
managing complications, and weaning and withdrawal versus upgrading.
00:51:16
Speaker
But you did cover a lot of very important concepts as an introduction.
00:51:20
Speaker
The one thing I do want to ask you before we wrap this part one up, Bindu, is obviously in the last couple of months, at least in the clinical trial arena,
00:51:32
Speaker
The Danger Shock RCT was published, and I think it's definitely a landmark paper moving forward as we start to see the impact of some of these devices, temporary support in patients with cardiogenic shock associated with MI.
00:51:49
Speaker
Any comments on this particular paper?
00:51:53
Speaker
I think that, number one, it was a prospector, multicenter, open-labeled RCT.
00:51:59
Speaker
It was done in Denmark, Germany, and UK over the last 10 years.
00:52:04
Speaker
360 patients from, I think, 18 to 90 years of age in STEMI, and the absolute reduction was about, number needed to treat was eight.
00:52:17
Speaker
So it was a 12.7% reduction in mortality rate.
00:52:21
Speaker
In fact, I was just going to sit with the fellows to go over this.
00:52:24
Speaker
And I think it's a good start in MCS in terms of it's the first RCT in AMI shock, which is one of the highest mortality, to achieve its primary endpoint.
00:52:37
Speaker
And you know physiologically it makes sense, but I think that big picture is...
00:52:46
Speaker
Science matters and we need to do more and more of these trials to see right patient, right support, right timing.
00:52:58
Speaker
And I am here to ask all of you as intensivists, if there was ever a need for us to really be in this field and move outcomes, it's now.
00:53:12
Speaker
And I hope more of you will join the MCS critical care community.
00:53:19
Speaker
Reach out if you want to learn more, obviously.
00:53:21
Speaker
But I think like this, we are learning together.
00:53:25
Speaker
So that's those are my thoughts on that, Sergio.
00:53:30
Speaker
Perfect.
00:53:31
Speaker
I know.
00:53:32
Speaker
So I think that we have a lot to talk about that will be in part two.
00:53:37
Speaker
But I do want to close the podcast, Bindu, with a couple of questions that are unrelated to MCS.
00:53:43
Speaker
Would that be OK?
00:53:44
Speaker
Yes.
00:53:44
Speaker
Yes.
00:53:45
Speaker
Go for it.
00:53:46
Speaker
So the first question relates to books.
00:53:49
Speaker
Are there any books or is there a book that has impacted you significantly or that you have gifted often to other people?
00:53:57
Speaker
Yeah, I think out of all the books that I've ever read, The Alchemist speaks to me.
00:54:04
Speaker
And I think as I'm getting older, it speaks to me a lot more.
00:54:09
Speaker
For those of you that read it, you must know.
00:54:12
Speaker
But if you didn't read it, I highly recommend it.
00:54:15
Speaker
And the central idea is that
00:54:18
Speaker
Everyone has this personal legend within them.
00:54:22
Speaker
And when we are young and we imagine this world full of possibility, that personal legend is like very clear.
00:54:30
Speaker
And the universe kind of puts clues in your way for you to be enthralled if you were to choose to see them.
00:54:38
Speaker
And then the universe comes together to make it happen for you.
00:54:44
Speaker
And I think like, and, and that's, there's a statement there.
00:54:49
Speaker
And I think that says, and when you want something, all the universe conspires to help you achieve it.
00:54:58
Speaker
And I think like, I look at my own, my, my own path.
00:55:03
Speaker
I mean, just like all of you, like we are, we are filled with potential and the only person that gets in the way is us.
00:55:09
Speaker
Right.
00:55:10
Speaker
Right.
00:55:12
Speaker
have come to realize that one of my own personal legends is to see people as having unbelievable potential and mentor them and be the miracle growth that they need.
00:55:27
Speaker
I mean, I'm a gardener at heart, so sorry.
00:55:29
Speaker
I'm not, I'm not supporting any brand, but I think that's what it is.
00:55:35
Speaker
Like, I hope
00:55:37
Speaker
I hope we really continue this improvement, right?
00:55:41
Speaker
So I think that book really speaks to me.
00:55:44
Speaker
And it's a free PDF online.
00:55:47
Speaker
So I don't even gift it.
00:55:48
Speaker
I just send the students and my mentees a link and I try to post on social media and my personal pages about it.
00:55:56
Speaker
It's like, it's so powerful, so powerful.
00:56:00
Speaker
Absolutely.
00:56:01
Speaker
A brilliant book, I agree, and we'll definitely put a link in the show notes.
Conclusion and Future Discussions
00:56:06
Speaker
I think this is the perfect place to take a pause and stop, Bindu, for today.
00:56:10
Speaker
We definitely will continue this conversation.
00:56:12
Speaker
I really want to thank you for sharing your passion for this topic, your knowledge, and I look forward to part two of our discussion where we dive into the managing of complications and troubleshooting of these MCS devices.
00:56:27
Speaker
Thank you so much, Sergio.
00:56:30
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:56:33
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:56:39
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:56:44
Speaker
To learn more, visit www.soundphysicians.com.