Can Your Heart Recover From Cardiogenic Shock?

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Michael Zhen-Yu Tong, MD:

Good morning. My name is Michael Tong. I am the surgical director of heart transplantation and MCS (mechanical circulatory support), and this morning I will be talking about our Cleveland Clinic strategy for patients with acute cardiogenic shock and our usage of temporary mechanical circulatory support. So in simplistic way of talking about it, we use short-term devices for short-term problems. We use long-term devices for long-term problems. So somebody comes in in cardiogenic shock, acute cardiogenic shock, this is the first time they present, or this is an acute worsening. This is when we want to use short-term devices, because as much as possible, we want to recover these patients. If they come in with a viral cardiomyopathy where they come in with an MI (myocardial infarction) and the heart is stunned, often we can recover their hearts, and we want to do everything we can to recover their hearts so that they can go on as long as they can with their own hearts.

So what do we do for these patients? And as we think about that, it's important to consider that this is some of the highest risk group of patients. Patients with acute MI, with cardiogenic shock has a 50% mortality, and this has been ever since the... For the last 30 years, we've made very little improvements in the outcome of these patients. Whether you revascularize them early or you just treat them medically, these patients either way have a very high mortality, about 50%.

And this is where mechanical support really comes in. And when we think about why this may be, we've done the best we can. We've opened the coronary, so you would think that this patient should be fixed. However, what's important to realize is that myocardial recovery takes time. So even though now you've revascularized the patient, it can take days for the myocardium to recover from that stunned state. So the theory is, if we can support these patients and normalize their hemodynamics while we wait for the beneficial effects of revascularization to take place, then we can have better survival rates and better outcomes.

So as we institute MCS for these patients, we are thinking about a priority of what we want to try to achieve, and it goes into the following sequence. So the number one thing is we want to normalize their blood pressure. And when we normalize the blood pressure, we can then normalize the end organ perfusion. So we want to make sure that the kidneys are perfused, the brain is perfused, and all the other vital organs are being perfused. However, that alone is not enough. So once we are perfusing the organs, the next thing we want to make sure is we have a platform that will ensure that the heart can recover.

So what we got to remember is we don't want to just normalize the hemodynamics, but then we also want to make sure that the heart is in the best condition for recovery and for weaning. And ultimately, if there is too much damage to the heart, we then want to make sure that we can buy time for this patient to have more advanced options down the road, so if we're thinking about LVAD, we're thinking about transplant for the patient. So we want to make sure that we can buy time safely for these patients, which means we want to have a strategy where we can extubate them as much as we can. We want to have a strategy where we can ambulate them as much as we can and make sure that their organs are as normal as possible.

So these are the devices that are available to us, that we use them most commonly. We have other devices too, but these are the most common ones. The balloon pump is probably the most common device they use in cardiac surgery, although the usage has slowly been decreasing. The Impella, we use a lot more of it. We use more Impellas than almost anybody. ECMO is still a device that we use very commonly. So our choices of device that we use depends on how much support we want for the patient. We do over 100 VA ECMOs a year, which is one of the largest programs in the world. When it comes to temporary devices, we also put in over 100 Impella devices a year surgically. This does not include the Impellas that are placed in the cath lab. These are only the surgically placed.

So in conclusion, when it comes to short-term devices, the goal is to normalize, number one, the blood flow to the body. We want to then think about what is the best and optimal strategy for the heart to recover. And we want to use a device that will provide enough support to the patient. And once the patient is on support, next thing we want to think about is weaning. How do we get this patient weaned? And if this patient is not weanable, then how do we safely bridge this patient to the next phase of treatment, which is LVAD or transplantation?

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts, or listen at clevelandclinic.org/loveyourheartpodcast.