 Good afternoon. I'm Andrew Savitello, an advanced heart failure and transplant cardiologist at Baylor-Saint-Lewis Medical Center and the Texas Heart Institute. I'm going to spend the next session discussing with you a team-based approach to the management of cardiogenic shock. What I'd like to do is set the stage by going over some simple definitions and then a brief discussion regarding the historical outcomes of cardiogenic shock. We'll then transition into the rationale for a team-based approach to the management of cardiogenic shock. We'll talk about cardiogenic shock team components and then we'll wind up talking about the outcomes associated with a team-based approach to cardiogenic shock management. So let's start with cardiogenic shock. So shock is of course hypotension resulting in hypoperfusion. Cardiogenic shock is a low cardiac output state due to cardiac damage or dysfunction which results in hypoperfusion. The initial deficit is a low cardiac output which then leads to increased pulmonary vascular congestion, culminating in ischemia, even in those without coronary artery disease, progressive myocardial dysfunction, and then potentially death. We tend to focus on these hemodynamic derangements because it's obvious and it's a target for intervention, but it's also important to remember that there's often a simultaneous systemic inflammatory malu with increased inflammatory cytokines and nitric oxide levels which paradoxically cause vasodilatation, often have a direct myocardial toxic injury, and further progression to myocardial dysfunction and death. And this inflammatory malu has also been associated with increased mortality rates and cardiogenic shock. So if we're going to talk about cardiogenic shock, I think it's important to try to establish what the historical outcomes have been. And we have a real paucity of randomized controlled trial data with regards to cardiogenic shock. These trials are very, very difficult to conduct and enroll in, primarily because of the emergent, time-sensitive nature of cardiogenic shock. So really, we have three major randomized controlled trials. All three of these trials really just address cardiogenic shock complicating and acute myocardial infarction. So this is the only data we have. Let's spend a few moments going over it. First of all, we have the shock trial, which was published in 1999. The shock trial looked at patients presenting with acute myocardial infarctions, complicated by cardiogenic shock. It randomized patients to either early revascularization or standard of care, which was medical therapy. The patients that underwent early revascularization had a better survival at 53% versus 44% for those undergoing medical care. This, of course, set the modern paradigm for the management of cardiogenic shock with acute myocardial infarction, focusing on early revascularization. In 2012, we got our next randomized trial, the intraagodic balloon pump shock II trial. This again looked at patients with acute myocardial infarctions, complicated by cardiogenic shock. There's been a lot of interest in supplementing revascularization with percutaneous hemodynamic support. So this trial randomized patients to revascularization with a PCI versus revascularization plus intraagodic balloon pump support. And what they found was that 30 days, one year and six years, there was absolutely no difference in mortality in those patients that simply underwent revascularization versus those that underwent revascularization with balloon pump support. So no proven benefit to intraagodic balloon pump support in patients with cardiogenic shock and acute myocardial infarction. Now, the survival in the trial was 60%, which was somewhat encouraging. So our survival went from 53% in the shock trial to 60% in the IABP shock II trial. Then came the culprit shock trial, which was published in 2017, which is quite a modern trial. This looked at patients again with cardiogenic shock, complicating and acute myocardial infarction, and looked at various revascularization strategies. So half the patients underwent multivessel PCI, and the other half the patient underwent culprit lesion only PCI. Patients that underwent culprit lesion only PCI had an improved survival, suggesting that focusing on culprit lesions only in these patients is superior. Patients that underwent multivessel PCI had a survival of 48%, but this was a very modern revascularization cardiogenic shock trial that again showed an overall survival in this trial of 53%, which was no different than the shock trial that was conducted 18 years earlier. So this was very disappointing, very sobering, and leads us into the rationale for a team-based approach to the management of cardiogenic shock. So we pointed out that the outcomes for cardiogenic shock over about an 18-year period were flat. So we have the shock trial, Hockman in 1999 with a 47% mortality. We have the IABP trial in 2012 with a 40% mortality, and then we have the Culpert PCI trial in 2017 with a 47% mortality. You know, over that 18-year period, there was a lot of improvement in technology and in ICU care management. Unfortunately, enterotic balloon pump counterpulsation showed absolutely no benefit in the outcomes of cardiogenic shock. There have been a lot of studies that looked at vasopressures and inotropes. You can improve cardiac output and support blood pressure with these agents, but have failed to demonstrate any improvement in survival and cardiogenic shock. There's been an awful lot of focus on the development and implementation and deployment of percutaneous mechanical circulatory support devices. So things like Tannum Heart, the entire family of impellic catheters and VA ECMO all provide vastly superior hemodynamic support compared to enterotic balloon pump counterpulsation. Unfortunately, none of these interventions have shown to provide a survival benefit in patients presenting with cardiogenic shock, complicating and acute myocardial infarction. So there's been a lot of discussion, there's been a lot written about why this might be the case. And part of what's been said is it's not so much the care that we're provided, it's how we're providing the care. And so I want to focus for just a minute on what I view as the standard cardiac emergency care paradigm. And this is really an offshoot of, you know, revascularization strategies that develop in the late 80s and early 90s. So a patient presents to the emergency department with acute myocardial infarction, the ER team triages the patient, they notify the STEMI team. The STEMI team comes in, they take the patient to the cardiac catheterization suite, they undergo percutaneous revascularization as feasible. And then the patient is transferred to a cardiac ICU or a medical ICU and then often there's another group of physicians taking care of the patients there. So this is a very siloed, non-standardized, non-protocolized way to take care of patients. These groups of physicians are not often talking to each other, certainly not on a moment to moment or even hour to hour basis. Now, cardiogenic shock has been sort of shoe-ordered into the same paradigm. So patients present to the emergency department with an AMI shock, the emergency department again triages them, they go to the cath lab, they undergo revascularization. Perhaps they get a percutaneous support device and then they're sent to the ICU where they either live or they die. And I think that this is not the optimal care delivery system for patients with cardiogenic shock. So let's go through this on a little bit more detail. So cardiogenic shock mortality has remained high as we pointed out despite improvements in therapeutic. The treatment is complex, time-sensitive and ideally multidisciplinary. There have been a lot of instances in acute and time-sensitive critical illnesses in which a team-based approach has clearly shown improved outcomes. So examples would be implementation of a code blue team, a rapid response team, a stroke team, or a trauma team. So in each of these instances, a team-based approach has improved outcomes. Cardiology has been a little bit slow to embrace the team approach. However, more recently, multidisciplinary heart teams are commonplace for the management of things like complicated cardiac arrhythmias, structural heart disease, heart transplantation, durable mechanical circulatory support, and complex coronary revascularization. I think it's reasonable to say that a team-based approach is now the standard of care for many complex cardiovascular conditions. If we go back to cardiogenic shock in particular, I don't know of any individual physician that has the background experience or bandwidth to triage shock patients, perform complex PCIs, obtain large-board vascular access or vascular cut-downs, place integrated sheets for limb perfusion, insert temporary mechanical circulatory support devices, manage temporary mechanical circulatory support devices, insert intermediate or durable surgical ventricular support devices, manage mechanical ventilatory support, manage metabolic arrangements including acute kidney injury requiring renal replacement therapy, manage complex cardiovascular arrangements, rapidly perform an interpretive invasive and non-invasive imaging, rapidly determine appropriate escalation of care including escalation of MCS, some possible emergent heart transplantation, and determine when further care is futile. So maybe there exists one or two people on the planet that have the ability to do all these things, but it's certainly not something that you can build a program around. And I think ideally you want a team of people to take care of each of these individual problems. There's been a lot of discussion nationally and internationally about the goals of a cardiogenic shock team. I think it's generally agreed that such a team would facilitate early recognition of cardiogenic shock. They would expedite multidisciplinary discussions regarding evaluation and management. With a real emphasis on the need for timely mechanical circulatory support, appropriate device selection of mechanical circulatory support, and appropriate escalation of care when needed. They would also streamline and standardize care of cardiogenic shock. There have been a lot written over the past couple of years about the rationale for a cardiogenic shock team. These are four publications that if you're all interested, I would highly recommend. They do a much better job of articulating the rationale for a cardiogenic shock team than I can possibly do in this 20-minute presentation. The American Heart Association in 2017 put out a scientific statement regarding contemporary management of cardiogenic shock. And within that document they describe a shock team. They have two different types of shock team that they describe. One is a mobile shock team. This would be a team that would go out to a referring hospital and assist with management and implantation and then transportation back to the cardiogenic shock hub. And they also describe the shock team at a hub cardiogenic shock center. So let's spend just a few moments describing what the shock team components might look like and how you might operationalize this. So the HA scientific statement that we just referenced goes into great detail about what the hospitals need to provide. So the hospitals need to provide ICU care. They need to have 24 hours a day, 7 days a week, either MD or APP staffing of the ICU. They need to have one-to-one nurse-to-patient ratios, be able to infuse vasoactive medications, provide mechanical ventilatory support, invasive hemodynamic monitoring, temporary pacing, renal replacement therapy. 24 hours a day, 7 days a week, primary PCI services, cardiac surgery, blend pump insertion. Percutaneous VAD insertion, implantable VAD insertion, ECMO and echocardiography. The document also goes into great detail about the physician and consultant components of the shock team. And it strongly recommends the presence of a cardiology interventionalist, an echocardiographer, an advanced heart failure transplant specialist, electrophysiologist, palliative care specialist, neurology, cardiology intensivist, or an ICU intensivist, cardiac surgery, nephrology, palliative care, which they mentioned twice, must be very important, pharmacy, social work, physical therapy, respiratory therapy, occupational therapy, and a dietitian. So these are all the members of the cardiogenic shock team. They would be deployed at various stages throughout the patient's care. So what does a prototypical shock team workflow look like? So if anywhere in your institution, cardiogenic shock is suspected, you want to have some mechanism to activate a shock team. And this initial shock team would consist of a critical care specialist, an advanced heart failure specialist, an interventional cardiologist, typically a cardiac surgeon and someone from a circulatory support team. The team would convey very quickly to perform a rapid multidisciplinary evaluation. They would perform invasive hemodynamic evaluation quickly and provide additional diagnostic studies, typically at least an echocardiogram, and very quickly come up with a therapeutic intervention selection. So how do you protocolize this? Well, when we protocolize this at Baylor Sanctus Medical Center, we wanted to make this as easy for the referring doctor as possible. So if anywhere in the institution, cardiogenic shock is either suspected or confirmed, you simply dial one phone number. So this is the number to our page operator, 4444, and ask for the heart failure failure to be paged to screen for shock, and that's all the referring physician or nurse has to do. What happens when that occurs? The heart failure failure would do an initial screen, confirm cardiogenic shock, and notify the advanced heart failure cardiologist, the advanced heart failure cardiologist, interventional cardiologist, and mechanical circulatory support intensivist. We'll have a brief phone conversation to discuss the patient and decide on a treatment plan, optimal device strategy, and exit strategy. Appropriate support personnel will then be activated for bedside or catholic MCS insertion, and after MCS is placed, the advanced heart failure MCS team will assume primary care in our cardiovascular ICU. So this is to give you an idea, just an example of some of the things that are all happening at the same time, give you an idea of how complicated that the management might be and why a team-based approach might be most appropriate. So we are doing serial assessments of things like lactate, cardiac output, cardiac power, pulmonary artery pressure index, and if MCS is in place, serial echocardiogram, serial assessments of homolysis, serial neurovascular assessments. We are consistently looking for criteria of refractory shock to see if escalation in care needs to be performed, utilizing cardiac power, cardiac index, pulmonary artery pressure index, and biomarkers particularly lactate. We want to very quickly look for contraindications to MCS, including anoxic brain injury, irreversible organ function, prohibitive vascular access, or a DNR status. The treatment objectives are to wean vasopressors and inotropos as quickly as possible, assess for MCS acceleration if patients have signs or symptoms of refractory shock, and evaluate for heart recovery. So the first thing we're going to do is look to see if the patient has findings of refractory shock. If they don't, then we're trying to wean inotropos and vasopressors and assess for heart recovery. If the patients have refractory shock, they're going to be categorized as biventricular shock, left dominant shock, or right dominant shock. The multidisciplinary shock team is going to be continuously conferring to assess candidacy for temporizing MCS or escalation in the current MCS strategy. If the patient has biventricular failure in their hypoxemic, they're going to get a right and left percutaneous ventricular assist device with an oxygenator or a VA ECMO. If they're not hypoxemic, then they'll get right and left percutaneous support. If the patients have dominant left-sided cardiogenic shock in their hypoxemic, they get a left-sided PVAD with an oxygenator or VA ECMO. If they're hypoxemic, if they're not hypoxemic, they get a left-sided PVAD. If they have right dominant cardiogenic shock in their hypoxemic, they get a right-sided PVAD with an oxygenator or VA ECMO. And if they're not hypoxemic, they get a right-sided PVET. So is this a snapshot in time of all the different things that are going on in the ICU to give you another example of why a team-based approach and having multiple people look at various portions of this might be ideal? So cardiogenic shock teams are starting to be implemented both nationally and internationally. And we're starting to get some preliminary data to show how implementation of these shock team affects outcomes. So the first thing that I want to ask is our shock outcomes improving. Showed this slide earlier and emphasized that over an 18-year period, there was absolutely no demonstrated improvement in the outcomes of cardiogenic shock. Very stagnant, very flat. However, in 2019, we had a report from the National Cardiogenic Shock Initiative that suggested a mortality of 28% or a survival of 72% in patients with AMA cardiogenic shock. And this was almost difficult to believe. This is, again, data from the National Cardiogenic Shock Initiative, which is an offshoot of the Detroit Cardiogenic Shock Initiative that has now been expanded to other institutions across North America. When I first saw this data, I thought, that's interesting. But perhaps a one-off. But we're getting more and more data from more and more centers. We have data from a Nova Heart and Vascular that clearly showed marked improvement at one year and two years, simply after initiation of a structured, protocolized, team-based approach to management of cardiogenic shock. We have similar data from the University of Utah, again showing improved mortality after institution of a team-based approach. And we have information, this report from the University of Ottawa that clearly showed, both in hospital, 30-day and long-term survival was better after they instituted a team-based approach to the management of cardiogenic shock at their institution. So very, very interesting preliminary data. I want to share one more piece of information with you. This is a publication that occurred late last year in Jack, Management and Outcomes of Cardiogenic Shock and Cardiac ICU's with versus without shock teams. This is data from the Critical Care Cardiology Trials Network Investigators. This is a consortium of academic institutions across North America, and what they did is they all reported data. 10 of the centers had shock teams in place, 14 of the centers did not, and they simply compared practice patterns and outcomes. So a couple pieces of interesting information. First, if you look at the initial device selection in institutions with a shock team versus without a shock team, the institutions with a shock team tend to focus on more advanced mechanical circulatory support, so things like MPALA and TANAMART. And the institutions without shock team tend to focus on less advanced modalities of support, like intraerotic balloon pumps. Now, it's unclear if this directly impacted survival, but it is very clear that there were some differences in practice patterns. More importantly, I think, is this slide. So we look at utilization of invasive human dynamic monitoring to guide therapy. So clearly, the institutions that had a shock team were more likely to use invasive human dynamic monitoring to guide therapy, and it's been clearly proven in cardiogenic shock the use of invasive human dynamic monitoring leads to better outcomes. We touched on this a moment ago, the utilization of mechanical circulatory support. Clearly, the institutions that had a shock team in place had more utilization of advanced mechanical circulatory support than the institutions that didn't, so a clear practice pattern difference. Most importantly, the panel on the right, the mortality was much lower in the institutions that had implemented a shock team approach than the academic institutions that had not instituted a shock team approach. So all very, very interesting data, again, supporting the use of a team-based approach to the management of cardiogenic shock. So a couple of summary points here. So despite advances in care, especially in temporary MCS, cardiogenic shock mortality has remained very high. Cardiogenic shock management is complex, time-sensitive, and ideally multidisciplinary. There are multiple expert consensus documents that have recommended a multidisciplinary team-based approach to the management of cardiogenic shock. There's emerging data that suggests that a team-based approach improves standardization of care in outcomes in cardiogenic shock. Cardiac centers with shock teams are more likely to utilize invasive hemodynamics to guide therapy, more likely to use advanced temporary mechanical circulatory support devices, and have a lower risk-adjusted cardiac shock mortality. And I'm going to stop there. I thank you for your time, and I'll be glad to answer any questions during the discussion period.