Parag C. Patel, M.D., a cardiothoracic surgeon specializing in heart failure and heart transplantation at Mayo Clinic in Florida, presents in the Advanced Heart Failure Grand Rounds series on hemodynamics in the selection and management of mechanical circulatory support in cardiogenic shock.
Thank you very much one. And thanks everybody for joining me a week before thanksgiving. We are now entering the world of mechanical circulatory support over the next several weeks will really be kind of focusing on this in terms of our lecture series and oh bashar is on this morning and bashar door Doctor Siri Apple, you will actually be giving our next talk in a couple weeks on surgical considerations. So um this is really going to focus on human dynamics in the selection of management of mechanical circulatory support in cardiogenic shock. And it's going to add on several of the basic kind of uh um M. O. Dynamic information that we discussed during chemo dynamics in the management of heart failure. So you'll see that a lot of the slides are similar to before and we're adding on what we've learned from our lectures in july and august. So as you know, I like actually giving clinical scenarios, which is sometimes hard to do with with zoom. So what I'll do is I'll just go through the case. I'll give everybody about um 10 seconds to think about the answer and then I'll well actually talk about the answer. Go from there. So our first case is a 63 year old with non ischemic cardiomyopathy. E f 25% comes in uh a federal with the blood pressure of 75/50 heart rate of 1 25 Respiratory rate of 20 and trace lower extremity edema. Um the lactaid is five. Labs are remarkable also for granting a 2.5 baselines. 1.4 LFTs are up at 600. Uh the proponents are normal. The patient was on debut to mean and through a picc line We were able to ascertain that the CVP was 20 so that right. Angel filling pressures were high And the S. vo two is 20%. All of the following are reasonable therapies to consider until further data is obtained. I gave you the answer before I push that there Except so which is not the appropriate choices. That mechanical circulatory support is not needed. And add Miller known is that at a balloon pump at an impeller SCP at a protect duo um considering impel a. R. P. And impel SCP or via external. So as you saw here. Um I think the answer that is the least reasonable is actually adding Miller known you have a patient who's quite hypotensive in renal failure is starting to develop organ dysfunction as well. Um And a very very low S. V. O. To 28%. So addition of additional anna tropes may not actually lead to a salvageable outcome. And so it's really important to notice or important to identify shock early before you get into metabolic disorders. Typically you start off with a hemo dynamic problem and then slowly over time you move towards a hemo metabolic problem and once you have a hero metabolic problem or cardio metabolic problem, it is much harder to dig yourself out of cardiogenic shock because then you're dealing with multi organ failure, you're dealing with a cd mia, the vasa pleasure from Macedonia and renal failure, et cetera. And so you know, when you start getting deeper into the chemo metabolic state, your equation is going to have to incorporate addressing all of these four issues. You need to consider circulatory support to allow for systemic profusion ventricular support to provide rVN low of improvement in coronary perfusion, particularly in your ischemic patients. And finally, you need renal and hepatic unloading to optimize uh thermodynamics from a from a renal function standpoint allow for further and loading the heart. And so really the idea here is that you want to identify cardiogenic shock early and if you're, the deeper your in this cardio metabolic kind of milieu, the more likely you're going to need stronger support. The other thing to realize is that once you start one or two drips, adding more drips really isn't going to help you much. So this is data from shock registry Um of about 200 patients. And they looked at survival based on a number of China troops went in cardiogenic shock. And as you can see here, once you hit The two in the show pressure had a number, you're out of your mortality is quite high when it 70%. And so you're not gonna get much bang for your buck. The higher china tropes, compressors you're going and um and so it's really important to think about therapies at that time. Um It's also important to note that you don't want to wait too long for mechanical circulatory support, especially those that are deep in cardio metabolic shock. Um This is the data also looking at the acute um i cardiogenic shock registry and looking at onset mechanical circulatory support implantation and its relation to in hospital survival rates as a function of shock. And so what you can see here is patients who had mechanical circulatory support within 75 minutes of presentation with cardiogenic shock had better outcomes compared to those who had a delay um in therapy. And so you know what we've learned over time is that triggers actually consider chemical? Certainly true support at our institution as well has actually earlier in the course of of cardiogenic shock. So what device do you use? How do you actually decide what device you're going to use when you decide? Okay, it's time for temporal mechanical circulatory support. I think the biggest thing to realize is that the different paths can lead to the same outcomes as long as you know the strengths and weaknesses of each path. So if you're going from Jacksonville to Alcala, You may be able to go three different routes, but you need to know the which route actually has issues. You know this this red route here has a lot of speed traps and so that may be a advantage or disadvantage to taking that in the same idea within Pellegrino in central and you really want to get an idea as to what the strengths and weaknesses of our each one and tailor the therapy based on the clinical presentation of the patient, your insulin. So there are several LV support options. These don't include all of them, but they include the majority that we typically use here at Mayo. And several of them actually involve options that can be used at several of the hospitals in north florida. So we have our balloon pump which is a pulse. It'll pump that is not entering the left ventricle. It actually sits within the aorta and I'll get into that in a minute. You have your axial flow pumps. One usually is, one type is placed within the femoral artery. So the CPI typically is placed within the femoral artery um and its usually utilized for short term support. The M. P. L. 5.5 can actually be placed in the axillary position um and actually provide a little bit longer term support and allow for um uh rehabilitation of a patient with support and then the centrifugal pumps with the lives in the heart heart. Basically you have a info panel that sits in um the aorta and then blood's pulled out to a centrifugal pump. Um I'm sorry I'm just going backwards here. We have a we have an inflow cannula that sits in the left atrium. That's placed actually it's actually placed retrograde up the I. V. C. And utilizing intra cardiac echo and a septal puncture. So blood is pulled from the left atrium goes into the uh into the pump and then is pushed up the the aorta and then via Akmal which we'll talk about in a second. So both the tandem and the Vietnam are extracorporeal pumps and These three orange corporal pumps over here. So let's talk about the features of each one settle with the balloon pump. Again it's it's within the aorta. It allows for diastolic office, the profusion. It also allows for systolic augmentation of four float by reduction and systemic vascular resistance. It sits in the area. It provides an augmentation of about 5l per minute. A flow Requested a small cannula size of 78 French. Um the femoral artery sizes uh that is required for a balloon pump is about four. Again, the balloon pump now, as you know, can also be placed in the uh uh in the subclavian axillary position as well. Um you do need synchrony or at least a stable rhythm for a balloon pump to work well. And a lot of you guys have managed to balloon pump like somebody's in a field with RVR scientist attack. And and those tend to be uh suboptimal situations for patients requiring support, balloon pump does not provide oxygen aider and when you look at the aerodynamic profile, the biggest thing it does is it uh with these. Absolutely. And by doing so you reduced LV. And increases for growth or kind of power. Of course, it also increases coronary perfusion through diastolic augmentation and inflation. Mamphela 2.5 and c. p. both of those are retrograde. Um um uh we placed through the area into the L. V. So basically pulls blood through the left ventricle and pushes it down the area provides around um uh three, maybe four liters per minute a flow. The cps definitely a stronger device of the 2.5. The Canada size is definitely bigger than the balloon pump, so maybe difficult to place in a really petite Or or a young petite female or female or a young patient cannot sizes are around 13 to 14 French. You do need a femoral artery size of around five. But the nice thing with this is you don't need synchrony or stable rhythm. This device doesn't have an oxygenate er when you're looking at kind of the hemo dynamic profiles, the biggest thing to kind of realizes that all three balloon pump and impel us will actually sorry about that. All three will actually improve after load Or reduce after load. All three will reduce L. G. D. P. But the impeller will actually reduce LV pre load as well When you actually look at the impeller 50 or 55. Um this again is kind of an extension of the impel a series over here. Typically again placed in the axillary axillary position by our surgical team. You can get around 5 to 5.5 liters of flow with this device, The Canada size is around 21 French. You need a sizable femoral artery of 78 mm. Um synchrony is not needed again and the hemo dynamic profile is about the same as all the other devices. Um The reason why we um typically utilize them fellow five or 55 over the C. P. Or 25 is if we feel we need prolonged mechanical support. Um It does have less hemodialysis um than the smaller devices. Um There is a risk for vascular complications with any of these devices, but one of the other nice profiles is that allows the patient to be ambulatory and allows us to kind of provide strong rehabilitation with that support. Um We talked earlier about the tandem heart. Again, it's a little bit of a tedious procedure because you do need to do a septal puncture in the Cath lab you need to play. Um But the one benefit of the tandem devices is that they have an oxygenate er that you can add. So um going through the profile Again this pulls blood out of the left atrium and pushes it up the er to you can get about five liters of flow. With this device, Canada sizes are 17 arterial, in 20 earthiness. Fellow artery sizes are around eight. You don't need a stable rhythm, You have the ability to utilize an oxygenate er. But the one thing to realize with the tandem heart and Emma, which I'm going to talk about in a second is that the after load increases because you have retrograde flow up the area. And so that makes it harder for a sicker heart to actually unload. And so you just have to watch your ability to unload when you actually increase after like this and also makes it harder for the L. V. Two kind of remodel over time and improved. So keep that in mind. And then when you have ECMO and you know there are multiple configurations of ECMO here is kind of a configuration of peripheral ECMO where we can pull blood out of the I. J. And pushes up push it up the femoral artery. Dr syria upolu. Um Recently the very nice upper extremity configuration for peripheral ECMO. In a patient with giant Salmaan card itis where he actually pulled blood out of the I. J. And they had a axillary placement of the uh the oxygenated blood. So are the cannula, um the axillary artery. And so when you have that type of configuration you can actually rehab the patient have the patient walk et cetera. And so when you actually look at the profile of the ECMO again many different configurations. The configuration I showed you, you're pulling blood out of the R. A. Are going into the aorta. You can imagine this provides both right and left support because you're completely bypassing The the right ventricle. All the other devices need uh need a functioning right ventricle. Um so invierno. The cannula sizes are 16 arterial 21 for Um uh for for Venus. Uh you need a femoral artery of around eight, you do not need a stable rhythm. Um an oxygen ator is available. So if you're worried about oxygenation, you really want to again think about Vietnam a or canned um heart. Again, your cardiac power is pretty strong, you're afloat is quite high. So that's one of the challenges with ECMO. Um And the rest of the profile is pretty similar. And that was left side of devices. And real quickly we'll talk about right side of devices. So in terms of right side of devices um there are devices that provide direct RV bypass and ones that provide indirect RV bypass. So when you talk about RV bypass, um uh the actual flow pump that we typically utilizes a impel A. R. P. Which is placed in the groin. You have the option to do place a protect deal catheter in the I. J. And provide um uh extracorporeal centrifugal flow that protects the RV. And so both of these are isolated RV devices. The benefit of the protect duo is that you have the ability to ambulance your patients. The impel RP is a pretty large device that sits in the, you know in the groin. All of these bypass the R. V. So you can see if you look at the circuits down here blood flows from the R. A. Directly to the P. A. So the assumption is, is when you're putting in these devices isolated so alone you have to make the assumption that the LV. Is going to be able to tolerate the increased blood flow. And so all three of these devices will markedly increase blood flow to the left. And you have to be certain that if you're going to do that that the left ventricle is able to to tolerate that increase pre load, indirect RV bypass involves via ECMO. And again you're pulling blood out the R. N. Going straight to the L. V. And so you're really bypassing this entire circuit. And so this is a very good choice for bi ventricular failure or isolated RV failure where you're not sure about the ability of the left ventricle. Because sometimes as you'll learn as I'll show you here shortly when you have a very weak LV. You're not actually challenging when you have a very weak RV. You're not actually challenging the LV much. And so you may not be able to appropriately assess the capabilities of the left ventricle. I'm going to stop there and answer any questions and then we'll keep on going. Are there any questions for the group? Okay, great. I'll keep on going here. So, um, how do you choose what is right? You know, there are certain things that you need to kind of assess when you try to decide what type of pump you're gonna use. So the first thing to keep in mind is the strength of each of these pumps. And so when you move from left to right, you're going to have greater Karnik power out for greater output from your device. So if you need a very strong device, you're really looking kind of at these three devices and pellet tandem and the ECMO, if you're looking at temporary or kind of lighter support for a shorter period of time, you're looking at kind of the balloon pump in the impeller cps. You're gonna look at cannula size as well. Again, smaller patients may not be able to tolerate some of these larger devices. And so you want to look at candela size and appropriately estimate the utilization based on the size of the artery or uh that you're going to utilize. And finally, you're going to also look at oxygenated and see whether you need an oxygen it or not. So if a patient as borderline oxygenation, you may not want to utilize. The device is on the left. You may want to consider vehicle or or tandem part. Now the most important thing is so these are features of the pump, but most importantly how you select your devices is utilization of the basic human dynamics. So invasive human dynamics are essential in the selection of temporary mechanical circulatory support. And you want to utilize the human dynamics to help yourself in terms of deciding what type of devices you need. Now the thing is is that I'm just going to remind you guys about some of the basics of thermodynamics. This is an extension of my prior lectures. But first of all, when you actually look at the data, the data actually supports utilization of invasive thermodynamics when you have acute M. I. And cardiogenic shock. So this is registered related data presented by Bill O. Neill in 2018 where they looked at I think it was around um 2 to 3000. No I'm sorry 1300 patients who underwent a cue to my cardiogenic shock through the registry. And they stratified patients and those who had no hemo dynamic monitoring and hemo dynamic monitoring. And those who actually had hemo dynamic monitoring had less mortality than those who had no hemo dynamic monitoring. And it may not be the swan that improves outcomes. But it may be the ability to utilize that data to optimize patients. Or maybe the expertise of the centre. Because most centers who utilizing geodynamic monitoring, maybe kind of large scale academic centers who are used to managing cigarette patients. And so again, how do we utilize thermodynamics? Thermodynamics? We need to think about three major components. Oh Hold on 1 2nd here. I apologize. Let's see here. I don't know why. I mean erase that there. I apologize. Um so when actually looking at looking at him, oh Dinah, looking at aerodynamics important too when you have a patient that's crash and you want to break it down into pre load, contract ill itty and after load. And it's important to note that shock involves a derangement in any of these three thermodynamic parameters. And so uh it's imperative that when you have somebody who's crashing you're going to want to estimate what's going on with these three components either invasively or minimally invasively or an example. And so um when you actually look at uh invasive thermodynamics, remember the rules of six is I think I taught that to you guys earlier. Um if you'd understand 6 12 and 24 you can actually derive all the normal numbers for invasive human dynamics. If you use the concept that um the atria and ventricles filled during diocese. So you need equalization and pressures and the and the ventricle and the vessels actually filled during Sicily. So you need equalization and pressures over there. So Rules of Sixes 6 12 24. You know that these filled during diocese. So that uh RV. Diastolic Pressure six. I know that this feels during the ghastly so that you know that the LV diastolic pressure is 12. No this feels during Sicily. So uh this is hawk pressures 1 2024. Okay. And um if you understand that you understand kind of what the normal way forms will look like when you put in a. P. A. Catheter. Typically six or so when you put it in the right atrium. Uh Typically 24/6 in the right ventricle 20 for over 12 and G. P. A. And around 12 when when you wedge. Um So that is uh involves your pre load. And then you also need to look at contract illit and resistance. We like using cardiac index. Um Normal cardiac index is 2.5 to 4.2 liters per minute per meter squared. And um in terms of resistance um systemic vascular resistance should be around 800 to 1200 dying seconds per centimeter to the fifth. Now if you have somebody who's crashing um and you don't have a central line in place. I mean you don't have a p. A Catherine place. You can start off with a poor man swan uh and utilize a central liner picc line with an adapter to look at the central venous pressure and the S. V. 02 Okay. In the normal S. V. 02 is around 60%. And it's important that when you interpret in S. V. 02 you understand that there are several parameters that can actually affect your S. V. 02 So oxygenation uh through the lungs can affect your S. C. 02 So if you have issues with oxygenation that can reduce your escrow to hemoglobin. Or or if you think of this like a train going around a circuit, the ability to carry oxygen um can affect your video to your output or the speed of the train and finally your oxygen consumption. Or your ability to pull off oxygen from the train track from the train um affects your S. 02 So in order to make the assumption that your S. C. 02 correlates with oxygen delivery, you have to make the assumption that your oxygen arrival, your oxygen carrying capacity in your oxygen uptake is relatively unchanged. And so if those three are unchanged, you can feel comfortable utilizing your S. V. 02 for output. So S. 02 again is a surrogate for index. If those three parameters are stable, remember on a venus blood gas, you're going to want to look at the S. V. 02% and not the P. 02 Sometimes people have had respiratory therapist report this number the 37 point to remember. It's not that it's the S. 02% that gives you the S. V. 02 And it's also important to note that the poor man swan may tell you whether the heart is the issue with shock but it's not going to distinguish in a granular level between R. V. L. V. Or by the failure. Okay and so it's really important to note that you need more granular information to really get an idea as to which of the three here are causing your issues. And so that's where we use kind of more advanced thermodynamics. So um the one parameter that we like using this cardiac power output. So cardiac power outputs an integrated measure cardiac function. It really accounts for two things that accounts for the flow generating capacity of the heart and the pressure generating capacity of the cardiovascular system. And it integrates the two. And so cardiac power operated calls map times cardiac output divided by 4 51. I like using Fahrenheit 4 51. The book, if you guys recall as a reminder as to that number And when you do map times cardiac output divided by 451. If your cardiac power outputs greater than .6, that's normal. And if it's less than .6 is abnormal and when it's abnormal, it suggests that your flow generating capacities of the heart or your pressure generating capacities are abnormal and you're going to have to address it. Now, I'll get into details on that in a second. The other thing to kind of realize when you actually get hemo dynamic measurements is that you have to remember the RV. Do not forget the RV. Because the RV needs to fill the LV in order for ford flow to occur. And we oftentimes forget the RV in the setting of cardiogenic shock. And so really when you have invasive thermodynamics, not only are you looking at the left side of pressures, but you're really going to utilize the right side of pressures and break down the invasive thermodynamics into right and left um flow. So you can actually get an idea as to what's going on and remember that after you place left sided support, right ventricular failure can actually worsen. So if you have a big baggy LV and you actually put left side of support in, you're going to actually make the LV get smaller, you're going to shift that septum leftward and you're going to actually increase pre load and so you're going to shift your lateral wall rightward. And so when you have a shift of the second leftward and the lateral rightward, you're changing morphology of the right ventricle and that in itself is going to lead to RV. Dysfunction. So how do we look at our V. Dysfunction? There are multiple different measurements. But I think this is a very simple tool to utilize. Um This is P. A. Pulse pressure index or poppy. Um So that stands for the ability of the P. A. To generate the RV. To generate a pressure. So that's P. A. Systolic minus P. A. Diastolic divided by your back floor, your central venous pressure. So pieces stock via by ph diastolic over CVP is poppy and bigger the poppy the better. So if you have uh no temporary support in place and your poppy is less than one that's abnormal. And if you have temporary mechanical support in place where you have an L. VOD And your poppy is less than 1.5 it's abnormal. So how do you integrate these hemo dynamic measurements when you have a patient on temporary support or not? On temporary supports? So the first question you're gonna ask is is there adequate flow? And so how do you assess for adequate flow? You look at your cardiac power output, you look at your S. C. 02 If it's greater than 60% or you can look at cardiac index and then if there's not adequate floats, if these parameters are low, okay then you want to go to question two and say if there's not adequate flow, is it because of the RV or is it because of inadequate LV. Support? And that's where you utilize your poppy. And if your poppy is less than 1.5 when you have a mechanical circulatory support, then then then you know the RV is your issue. And if you're Poppy is greater than 1.5, then you really need to pay attention to the L. B. And C. Is your support adequate? You can use pay pulse pressure, CVP and RV topsy as well. Um but we typically hear we'll start off with the poppy um to to to troubleshoot. Now this is the most important slide from a thermodynamic standpoint for our fellows today. Um You know, I think this kind of sums up everything I've kind of taught you is that when you have a patient and if there is refractory shock, What you're gonna want to do is you're gonna want to break it down into three Texas shock by ventricular shock, LV dominant shock and RV dominant shock. So, um let's start off with parameters for LV dominant cardiogenic shock and LV dominant cardiogenic shock. You will have a low cardiac power output less than 0.6 you will have a normal pot or borderline poppy. So in this case one, so as you if you go through the questions, you do you have enough ford flow? No, because the cpos less than 10.6. Is it because of the right side? No, because your poppy is greater than one point. Oh and typically in these patients you'll have a lower era in a higher wedge. Okay. And that kind of dictator shows that your problem is LV dominant, an RV dominant cardiogenic shock. You'll have a low cardiac output. But the problem is your your right side. And so your poppy is going to be low and your R. A. Is typically going to be higher than your wedge. So you'll have an R. A bigger than the 15 and your wedge is going to be less than 15. And so if you have this thermodynamic profile, you're typically dealing with RV dominant cardiogenic shock. And then by ventricular shock basically you're going to have a low cardiac power output. You're gonna have a low poppy. So this is suggesting right sided failure. But the difference is that you're still having a high wedge. And so typically when you have isolated RV dysfunction that severe, you're not able to push right to left and so you're not able to generate a high wedge and by ventricular failure, typically you're going to have a high wedge as well. And so when you have that high wage, that is your sign that maybe it's not just the right side that maybe you're also dealing with left side of failure. So once you identify the type of cardiogenic shock, the next step is going to be looking at whether you have hypoglycemia or not. If you have hypoglycemia, again, your choice for temporary support becomes limited. Um, so if you have hypoglycemia and you have by ventricular failure, you really need to think about the tandem harder or the via ECMO circuit or central bag with an oxygen, ator bilateral central bag with an accident by ventricular central bag with an oxygen. Later, if you do not have hypoglycemia then and you have by ventricular failure, you can think of a by paella or a tandem heart with the protect duo. There are many different left and right configurations you can do or you can still just consider via ECMO as well. If you have LV dominant cardiogenic shock without, I'm sorry, with hypoxia. Again, vehicle or can um, heart, if you don't have hypoxia, then you can use one of the impeller devices. If you think it's going to be for more than a day or two. Really consider the 50 if you have the surgical team and the availability so that you can ambulance your patients if you have right sided dominant cardiogenic shock and um and you have hypoxia then again to an artificial heart and via ECMO or what you're gonna want to consider. And if there's no hypoglycemia then think about a right sided in Pella or protect duo. Okay. How do you know there's no cardiogenic shock or it's not re factory. It's when your CPU is greater than .6 your pop is greater than 1.5 and you're filling pressures are low. And if you have this then you really can start thinking about weaning your temporary support once your metabolic disarray is optimized. And as you develop party optimization of thermodynamics and as you develop recovery. And it's also important to note that it's more than just the aerodynamics and you really need to think about a bridge to wear. You know 98 year old uh in a nursing home who is wheelchair bound um coming in cardiogenic shock may not benefit long term from temporary mechanical circulatory support. And so what we like doing here is we like involving a multidisciplinary discussion with our intensive ist interventional cardiology ct surgery are transplant team sometimes palliative care and the E. R. Is also involved. But really we want to have our have our team do a multidisciplinary assessment so we can make sure that if we are going to commit to this route that we give the patient the best possible option and that the patient has the best possible chance at improving. So with all that information. Now let's get to our questions. So let's go back to that patient who came in with low output heart failure. Lactaid of five LFTs are high troponin looked okay, let's give you a thermodynamics this time. And let's say that the map is 50. The cardiac output is 1.5, the CVP is 18. The PPA is 24/14. Your wedges 12 and your co two is 46%. So what form of mechanical circulatory support is best? I'll give you guys a couple of seconds to think about this. So in this case we want to go back to the hemo dynamic profiles that I talked to you about. I I talked about. So we want to look at what is the cardiac power output and what is the P. A pulse pressure index? So cardiac power output. Remember his mean arterial pressure times cardiac output divided by 4 51. And I calculated that to be 0.17 and the poppy is the P. A. Systolic minus the P. A. Diastolic divided by the CVP. And and that is .56. So in this case you have a low cardiac power output and you have a low poppy and then you're going to look at the wedge because the wedges high then you're dealing with bi ventricular failure. But in this case the wedge is actually looking okay. And so in this case what you're probably dealing with is RV failure. And so when you go to this question and you say which form of mechanical circulatory support is best? You're really thinking about either a protect duo R. P. And C. P. M paella or Vietnam because all of these support the right side. Any questions so far? Okay great. So um remember you don't want to forget the RV and remember that RV failure can mask LV failure and so keep this in mind as we go through this question for a second year. So um sometimes you may not know the left side of capabilities of heart because the rights not challenging the left. And so um let's let's get we're gonna skip this for a second. We're gonna go to that question here for a second. So in the same case you have the patient and you decided to put a CPM paella in place. Okay. And 24 hours later the lactate is not improving. The LFTs is worsening, are worsening and the cramp is worsening. You look at your chemo dynamics and you're mean arterial pressure is 57, your cardiac output is 33.2 your C. V. P. S. 11, your p pressures 45/20 your wedges 18 U. S. C. 02 is 55%. This time you actually directly calculate your cardiac car output. It's .4. So that is low. But your poppy is okay. So this is a case where you actually um I this is this is a case. We're no I apologize. This should be in Pella RP. RP is placed but this is a case. This should be our p I mean change it for you guys here. But this is a case where this is a case. I'm sorry the slides kind of move forward. We should be here. So we put our pm paella in the patient. Um And you're mean arterial pressure is 51 your C. V. P. S. 12 your wedges 23 you're C. 02 is 38%. Your cardiac power output is low and your poppy is adequate. So which form of mechanical circulatory support is best here you have a patient with low cardiac output and an adequate poppy. And so in this case you will need um uh left sided support. And so here's a case where you put a right sided device in and you unmasked left sided failure. And so the options for this patient is actually going to be an rpm paella or CPM paella or via ECMO. Okay. And so if you put a right sided impeller in place and somebody who has right sided failure, you're not done. You need to actually look at him. Oh dynamics subsequently and see. Is that support adequate? Do we need to do anything else? Okay and so again the RV RV may unmask LV failure. And this is kind of a by pila placement for for for patient where you actually have a impel SCP um uh sitting in the left ventricle and an rpm paella on the right. And that can provide by ventricular support. Especially for people who don't need oxygenation or if you're going to do it short term, remember both of these are placed in the groin. So that is 1 um one kind of issue with regards to that. Okay, so now we're gonna change this um uh we're gonna go back to this uh this case here and um you put the CPM paella in the lactate. Still worse. The croutons worse again, these are the thermodynamics with the CVP of 11 P. A. Of 45/20 wedge of 18 and S. C. 02 of 55%. In this case you have a low cardiac power output and you have a poppy of 2.3. Okay, so you have low forward flow but you're right side of supports. Okay? Even though you have an R. P. And SCP impel in place. So this is a case where your CPM paella is not strong enough and you need to think about either upgrading to a five or 55 in Pella or progressing towards vOC moment. So in this case they didn't give you the option for a 50 in Pella or 55 impala. So you would want to advance to via ECMO. And so pearls for this case is remember that the right is tightly linked to the left. Okay. You need continuous assessment of him. Oh dynamics. To optimize temporal mechanical circulatory support. Even after you provide the support. And then remember this is that addition of isolated RV support is not adequate when you have severe metabolic disarray or LV myocardial depression. So if you're left ventricles week and your wedges higher than than maybe 15, just putting in a right side of devices not enough. And the other thing to keep in mind is sometimes when you have a lactaid of 10 um even though you had adequate LV function um uh prior to hemo dynamic compromise um support of with the right side alone may not be enough because the left side maybe injured from the metabolic disarray. And so sometimes when you have severe metabolic disarray, even if you feel the left side of the heart is strong enough to support a right sided device you may need to consider um by ventricular support. Any questions so far? Doctor Patel. Yeah I do have a question. Um So is this decision made? You know whether you want to support the RV or the LV. Prior to them getting there getting a device implanted, like for example if someone does have if it's their RV that's failing but you're not sure is the L. V. Going to be able to keep up or is the metabolic disarray going to resolve? Are you just making that decision that we're going to do RV and LV support prior to them getting the RV device? So in my in my opinion, I think it's best to utilize thermodynamics if you have the time and ability. So obviously the patient's crashing in minutes count. Sometimes you throw in a device whatever you think is going on and then you get your hemo dynamic subsequently to assess to assess adequacy of support. But in the ideal world, which is not always the case, you would use your chemo dynamics to decide. And then if you guess one way and you uh it's important that you have a swan in place to see if your guess was correct. And so let's say you even have him oh dynamics. And it looks like the right side uh is the issue on the left is and even after you place the right side of device, you should be following him. Oh dynamics. Because the left side of failure may unmask four hours later, six hours later, even 12 hours later. And so you really want to kind of watch it and it in in real time. Does that answer it? Yeah. Thank you. Right. So here's an example where actually the opposite occurred. So I told you that whenever you put the right side of device, be aware of left sided failure also remember that when you put the right side of device in, I mean the left side of device in um so whenever you put a left side device and you want to also be aware of the possibility of provoking RV dysfunction. So here's a patient that was hypotensive pressures in the eighties A. P. A pressure of 50/30 denarii of 30. And they actually put a C. P. A left side of device in the patient and a patient that is already has a poppy that's under one. Okay? And so what you can see here and this is a real patient A C. P. Is placed. And what you can see here is that the P. A. Really didn't change much. Your maps really didn't change much. But the one thing you notice is that your are a pressure shot up so you've increased your pre load to the right side with the already weak are A. So then you have coupling of your R. A. And your P. A. Pressures. When you have a coupling in your RMP pressures, you're really dealing with RV dysfunction. Okay and so in this case again air pressure is the same. Ph goes up. Our egos. I mean ph goes mildly up but more importantly the R. A. Significantly goes up and you have our A. To pay coupling. And so the in the Cath lab they recognize this and so they put an rpm paella in place. And this is where you start seeing adequate forward flow because now the right is pushing to the left and so you see your air pressures go up. Your pressure is actually kind of improved because or go up a little bit because you have right sided flow into the P. A. And you're are a pressure actually goes down. So you have are a two P. A. Uncoupling. So you have a separation between your RMP away forms suggesting you're having adequate right sided right sided flows with this device. And so just remember, I just want to highlight that the right and the left are tightly linked. And you really want to kind of look at how both are performing both before and after temporary support. Um in conclusion, I really want to understand that each type of mechanical circulatory support has both strengths and weaknesses. The support selection is tightly linked to him. Oh dynamics and is a fluid processes as I told, you know, this is you may put in one type of device and then if it doesn't work you may need to add a different device or change it out. So you want to use those hemo dynamics to help you make decisions. And then a multidisciplinary approach is imperative to determine support type and I should add one more here is that it's imperative to identify cardiogenic shock early and consider mechanical support or transfer to a place that can give mechanical support early before your deep into cardio metabolic disarray. Because once you're deep into cardio metabolic disarray, your ability to pull yourself out is very difficult. And so with that I wanted to thank you and open it up to any additional questions. So um one of the things that people always ask is how often you need to do this human dynamics. You know, they said you have to recheck thermodynamics, you do them every six hours every 12 hours uh in order to change your management so often in practice, do you change your settings uh based on the more than adverts are? Or how often you do him more than I mix to change your settings? So that's a great question. I think um I like I like doing the medina I mean You know checking him out like full full set of thermodynamics every 6-12 hours I think is enough. Um If somebody is steady. But if somebody is very unsteady then you want to use those thermodynamics rather frequently to um figure out what's going on from the thermodynamic standpoint and troubleshoot the patient. I really feel that you know one of the things when we get calls from um different facilities I think we see an underutilization of labs and and thermodynamics etcetera. And so um you know people are getting labs in general maybe um once once a once a once a day or twice a day and you really want to make sure that you're getting your labs you know every six hours you're checking an L. D. H. You're checking your lactate. You're getting your LFTs every 6 to 8 hours so that you can trend people because these are the sickest of the sick patients in the hospital and you want to make sure that you give your patients the best chance at survival. And so I think legalization of human dynamics every six to It's eight hours in a stable patient and more frequently. Unless what do you think? 1? Yeah I agree. I mean I think that the way we would do it and the clinic is of course when we were out in the morning and then again when we uh ran for the second time formally in the afternoon around four or five p.m. So we do at least twice a day and we write the numbers on the board and the in the room. So that way people can see what what the numbers were and they can see the trend. Um and I think that the whole situation, if the patient declined suddenly or that's will be the other time to do the hydrodynamic. So it won't be unusual that, you know, someone is crashes in the middle of the night and, you know, we come in and know him. More dynamics have been done. There's just the same swan in the um and pulse and blood pressure there on the screen. But nobody has calculates bopp etcetera. Go I agree. Any other questions at all? All right. So next week we do not have um Journal Club. You get to enjoy your thanksgiving weekend, stay safe out there. And then we will catch up the following week with dr syria appaloosa surgical surgical considerations for temporary mechanicals for support. Doctor Leonie. Any final words sir. Don't eat too much turkey. Uh huh. Thanks guys.