Teamwork in Acute Heart Failure: The Role of the Cardiac Anesthesiologist

Abstract

CARDIOVASCULAR DISEASE leading to heart failure is the most important cause of death worldwide, and poses a substantial burden on healthcare resources and personnel. Despite significant improvement in management, there has not been substantial decreases in the risks of readmission and mortality at 30 days.1Ko DT Khera R Lau G et al.Readmission and mortality after hospitalization for myocardial infarction and heat failure.J Am Coll Cardiol. 2020; 75: 736-746Crossref PubMed Scopus (22) Google Scholar The general tendency among clinicians is to hospitalize patients presenting with acute heart failure due to the uncertainty of risk of adverse events coupled with inadequate facilities for rapid follow-up. Such a decision is subjective and based on an individual's clinical judgment. This might result in some high-risk patients getting discharged (subjecting them to the risk of adverse events), and some low-risk patients getting admitted when they could have been discharged and followed up in an outpatient clinic. Hence, a strategy to guide the decision-making process that helps to triage these patients can be useful to clinicians. Such a strategy should be aimed at substantially reducing low-risk hospital admissions and avoiding high-risk discharges. In a recent paper, Lee et al. discussed the utility of the point-of-care algorithm to stratify patients with acute heart failure according to the risk of death.2Lee DS Straus SE Farkouh ME et al.Trial of an intervention to improve acute heart failure outcomes.N Engl J Med. 2023; 388: 22-32Crossref Scopus (3) Google Scholar The patients could be classified as low-, intermediate-, or high-risk, and only high-risk patients were hospitalized, whereas low- and intermediate-risk patients were given access to rapid-heart-failure clinics where a cardiologist attended to them. The point-of-care algorithm used a method for acute heart failure risk stratification—the Emergency Heart failure Mortality Risk Grade for 30-day mortality—which is a modification of an earlier model of the Emergency Heart failure Mortality Risk Grade that was developed by the authors, with one additional variable, ST-depression.3Lee DS Stitt A Austin PC et al.Prediction of heart failure mortality in emergent care: A cohort study.Ann Intern Med. 2012; 156: 767-775Crossref PubMed Scopus (194) Google Scholar It is reasonable to believe that risk stratification and rationalizing the hospitalization would impact the patient outcome. Indeed, the results of the study showed improvements in 30-day mortality and readmission. Prima facie, the implementation of such an algorithm seemed to be of little consequence to cardiac anesthesia practice; however, a closer look was suggestive of a significant impact. This editorial delves into this aspect of the paper. Those patients who are not hospitalized and returned to the heart failure clinic are likely to undergo pre-habilitation and, if necessary, are subjected to elective intervention and/or surgery. On the contrary, high-risk patients who are hospitalized are likely to be sicker, requiring early intervention. Timely therapeutic interventions are needed in such patients to improve the outcome, and the cardiac anesthesiologist is expected to be an integral part of the care provided to them. A substantial number of patients with acute heart failure are likely to have heart failure with preserved ejection fraction. Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction.4Pagel PS Tawil JN Bottcher BT et al.Heart failure with preserved ejection fraction: A comprehensive review and update of diagnosis, pathophysiology, treatment, and perioperative implications.J Cardiothorac Vasc Anesth. 2021; 35: 1839-1859Abstract Full Text Full Text PDF Scopus (12) Google Scholar The cardiac anesthesiologist should be familiar with this complex clinical syndrome to provide optimal care, a subject that has been reviewed recently.4Pagel PS Tawil JN Bottcher BT et al.Heart failure with preserved ejection fraction: A comprehensive review and update of diagnosis, pathophysiology, treatment, and perioperative implications.J Cardiothorac Vasc Anesth. 2021; 35: 1839-1859Abstract Full Text Full Text PDF Scopus (12) Google Scholar Likewise, the more familiar left ventricular systolic heart failure also constitutes a high-risk disease. The use of perioperative echocardiography, mechanical circulatory assist devices, and customized pharmacologic management is essential for managing these patients.5Henes J Rosenberger P. Systolic heart failure: Diagnosis and therapy.Curr Opin Anesthesiol. 2016; 29: 55-60Crossref Scopus (6) Google Scholar The burden is likely to increase in the face of only high-risk patients getting admitted due to the application of the algorithm. Among the patients with acute heart failure, some may progress to cardiogenic shock.6Goldberg RJ Gore JM Alpert JS et al.Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988.N Engl J Med. 1991; 325: 1117-1122Crossref PubMed Scopus (420) Google Scholar These are a group of patients who are at high risk of death and morbidity.6Goldberg RJ Gore JM Alpert JS et al.Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988.N Engl J Med. 1991; 325: 1117-1122Crossref PubMed Scopus (420) Google Scholar, 7Babaev A Frederick PD Pasta DJ et al.Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock.JAMA. 2005; 294: 448-454Crossref PubMed Scopus (543) Google Scholar, 8Hochman JS Buller CE Sleeper LA et al.Cardiogenic shock complicating acute myocardial infarction-etiologies, management and outcome: A report from the SHOCK Trial Registry. Should we emergently revascularize Occluded Coronaries for cardiogenic shock?.J Am Coll Cardiol. 2000; 36: 1063-1070Crossref PubMed Scopus (565) Google Scholar, 9Hochman JS Sleeper LA Webb JG et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2239) Google Scholar These patients can have a wide spectrum of presentations, ranging from those on modest inotropic support to those on mechanical circulatory support or receiving active resuscitation. In addition, patients may suffer from mechanical complications of myocardial infarction, such as ventricular septal rupture and ischemic mitral regurgitation. It has been reported that this group of patients comprises 2.1% of the total coronary artery bypass grafting (CABG) population, but 20.2% of CABG mortality.10Sergeant P Meyns B Wouters P et al.Long-term outcome after coronary artery bypass grafting in cardiogenic shock or cardiopulmonary resuscitation.J Thorac Cardiovasc Surg. 2003; 126: 1279-1286Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The hospital mortality of isolated CABG in cardiogenic shock ranges between 18% and 50%;11Ibrahim M Spelde AE Gutsche JT et al.Coronary artery bypass grafting in cardiogenic shock: Decision-making, management options, and outcomes.J Cardiothorac Vasc Anesth. 2021; 35: 2144-2154Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar whereas, when combined with valve repair and/or replacement or repair of ventricular septal rupture, it can exceed 60%.12Mehta RH Grab JD O'Brien SM et al.Clinical characteristics and in-hospital outcomes of patients with cardiogenic shock undergoing coronary artery bypass surgery: Insights from the Society of Thoracic Surgeons National Cardiac Database.Circulation. 2008; 117: 876-885Crossref PubMed Scopus (53) Google Scholar Despite high hospital mortality, those who survive the initial hospitalization exhibit a significant long-term survival,10Sergeant P Meyns B Wouters P et al.Long-term outcome after coronary artery bypass grafting in cardiogenic shock or cardiopulmonary resuscitation.J Thorac Cardiovasc Surg. 2003; 126: 1279-1286Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and there is an improving trend in the long-term survival of these patients.13Acharya D Gulack BC Loyaga-Rendon RY et al.Clinical characteristics and outcomes of patients with myocardial infarction and cardiogenic shock undergoing coronary artery bypass surgery: Data from the Society of Thoracic Surgeons national Database.Ann Thorac Surg. 2016; 101: 558-566Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar However, these patients also have a turbulent postoperative course, with a median intensive care unit stay of 96 days.12Mehta RH Grab JD O'Brien SM et al.Clinical characteristics and in-hospital outcomes of patients with cardiogenic shock undergoing coronary artery bypass surgery: Insights from the Society of Thoracic Surgeons National Cardiac Database.Circulation. 2008; 117: 876-885Crossref PubMed Scopus (53) Google Scholar The cardiac anesthesiologist would be a part of the management of these patients during the entire course in the hospital. In addition to their usual responsibilities of providing monitored anesthesia care and general anesthesia, they would be faced with institution and/or weaning from mechanical support devices. The advent of mechanical support devices, such as left ventricular assist devices and venoarterial extracorporeal membrane oxygenation (VA ECMO), have influenced the decision-making process. Consequently, the cardiac anesthesiologist, who is an active member of the multidisciplinary team, must be familiar with the technicalities (knowledge and skill) involved in the management of such patients, as these interventions are commonly required by them. They will have to participate in not only the execution of the mechanical interventions, but also perioperative and/or periprocedural management of these patients. Over the years, mechanical circulatory support devices have been deployed more frequently. Among these, the intra-aortic balloon pump is the most common, with Impella (Abiomed, Inc) being the most deployed nonintra-aortic balloon pump mechanical circulatory support preoperatively, and ECMO being the most commonly used postoperative modality.13Acharya D Gulack BC Loyaga-Rendon RY et al.Clinical characteristics and outcomes of patients with myocardial infarction and cardiogenic shock undergoing coronary artery bypass surgery: Data from the Society of Thoracic Surgeons national Database.Ann Thorac Surg. 2016; 101: 558-566Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar ECMO is likely to have an increasing role in cardiogenic shock patients, and has been shown to have a reasonable outcome.14Esper SA Bermudez C Dueweke EJ et al.Extracorporeal membrane oxygenation support in acute coronary syndromes complicated by cardiogenic shock.Catheter Cardiovasc Interv. 2015; 86: S45-S50Crossref PubMed Scopus (41) Google Scholar The institution and management of temporary mechanical circulatory support and transition to permanent mechanical circulatory support with or without revascularization will have an expanding role in the future.11Ibrahim M Spelde AE Gutsche JT et al.Coronary artery bypass grafting in cardiogenic shock: Decision-making, management options, and outcomes.J Cardiothorac Vasc Anesth. 2021; 35: 2144-2154Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Early preoperative institution of ECMO has been shown to lead to better outcomes than when placed postoperatively.15Hamiko M Slottosch I Scherner M et al.Timely extracorporeal membrane oxygenation assist reduces mortality after bypass surgery in patients with acute myocardial infarction.J Card Surg. 2019; 34: 1243-1255Crossref PubMed Scopus (6) Google Scholar The use of Impella and ECMO together also has been proposed.16Papparardo F Schulte C Pieri M et al.Concomitant implantation of Impella® on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock.Eur J Heart Fail. 2017; 19: 404-412Crossref Scopus (321) Google Scholar ECMO is a useful device that has been used mainly in the management of patients with cardiogenic shock or respiratory failure that is unresponsive to conventional pharmacologic therapy. Percutaneous femoral VA ECMO has the advantage of being rapidly deployable, both at the bedside and in the operating room, and can be initiated without the need for general anesthesia.17Odonkor PN Stansbury L Garcia JP et al.Perioperative management of adult surgical patients on extracorporeal membrane oxygenation support.J Cardiothorac Vasc Anesth. 2013; 27: 329-344Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In the operating room, if the chest is open, central VA ECMO with the right upper pulmonary vein vent can be initiated.18Pavlushkov E Berman M Valchanov K et al.Cannulation techniques for extracorporeal life support.Ann Transl Med. 2017; 5: 70Crossref PubMed Scopus (96) Google Scholar Other options include the TandemHeart (LivaNova, PLC) and the Impella devices. Both have minimally invasive surgical options. A continuous-flow centrifugal pump is incorporated in TandemHeart, and a microaxial impeller is incorporated in the Impella device. For percutaneous application, a left atrial-to femoral bypass is used. The left atrial catheter is placed via a trans-septal puncture from a femoral or internal jugular vein approach. Levosimendan is an attractive agent that has inodilatory properties in the face of reduced pulmonary vascular resistance.19Nieminen MS Akkila J Hasenfuss G et al.Hemodynamic and neurohumoral effects of continuous infusion of levosimendan in patients with congestive heart failure.J Am Coll Cardiol. 2000; 36: 1903-1912Crossref PubMed Scopus (343) Google Scholar,20Papp Z Agostoni P Alvarez J et al.Levosimendan efficacy and safety 20 years of SIMDAX in clinical use.Card Fail Rev. 2020; 6: e19Crossref PubMed Google Scholar With this background, it is easy to appreciate that the cardiac anesthesiologist will have a major role to play in the perioperative management of patients who present with acute heart failure, especially those in cardiogenic shock. Optimizing the intravascular volume, oxygenation, electrolyte and metabolic imbalances, inotropic support, mechanical ventilation, and institution of mechanical circulatory support are the fundamental needs of these patients that can be met by the cardiac anesthesiologist. It is now proven that early revascularization (<18 hours) in the form of percutaneous coronary interventions (PCI) or CABG decreases the 6-month mortality of patients with cardiogenic shock.9Hochman JS Sleeper LA Webb JG et al.Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock.N Engl J Med. 1999; 341: 625-634Crossref PubMed Scopus (2239) Google Scholar Whether PCI or CABG is better in this subset of patients is a moot question. There are no randomized data comparing the 2 in this subset of patients, but favorable outcomes have been reported with CABG.11Ibrahim M Spelde AE Gutsche JT et al.Coronary artery bypass grafting in cardiogenic shock: Decision-making, management options, and outcomes.J Cardiothorac Vasc Anesth. 2021; 35: 2144-2154Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Selection bias may explain some of the favorable results. Patients who present in cardiac arrest and require cardiopulmonary resuscitation before or during surgery pose significant challenges and demand a high degree of technical expertise from the treating doctors. Although such patients have high mortality and morbidity after CABG, the available data suggest that some of these patients can have meaningful survival and, hence, CABG should be a consideration in select patients.11Ibrahim M Spelde AE Gutsche JT et al.Coronary artery bypass grafting in cardiogenic shock: Decision-making, management options, and outcomes.J Cardiothorac Vasc Anesth. 2021; 35: 2144-2154Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Availability of the surgeon during induction of anesthesia should be ensured for an early sternotomy, if necessary. Blood and blood products should be readily available due to the recent use of anticoagulation and anti-platelet medication. A comprehensive transesophageal echocardiographic examination should be performed to make decisions regarding not only hemodynamic management but also the adequacy of surgical correction. In conclusion, patients presenting with acute heart failure pose unique challenges, especially those in cardiogenic shock. Cardiac anesthesiologists will see a growing role in hemodynamic management along with transesophageal echocardiographic guidance in these patients, if the triaging proposed by Lee et al. is adopted by the clinicians. More high-risk patients are likely to be encountered with this strategy, and the cardiac anesthesiologist will be an important team member participating in decision-making regarding complete revascularization (PCI or CABG). Of note, the institution of mechanical support and postoperative management of these patients who are vulnerable to suffering from pulmonary, renal, and neurologic morbidity should be the priority areas. The author is the Section Editor of the Journal of Cardiothoracic and Vascular Anesthesia.