Value of Multi-Disciplinary Systematic Evaluation of Acute Mechanical Circulatory Support for Cardiogenic Shock in a Regional Non-Transplant LVAD Center.

Abstract

Background Cardiogenic shock (CS) remains a disease entity with an unacceptably high mortality. Early recognition provides the possibility of instituting therapies that can promote myocardial recovery and/or safer transition to a durable solution such as left ventricular assist device or heart transplant. Purpose The complexity and heterogeneity of CS patients requires expertise and longitudinal coordination of care. Early recognition and timely intervention remains paramount in this subset of patients. The aim this research is to examine the benefits of implementing a systematic approach to CS patients directed by a multidisciplinary team. Methods Descriptive retrospective chart review of 43 patients receiving acute mechanical circulatory support (AMCS) via Impella (CP or 5.0) with or without VA-ECMO for the indications of CS during a period from 2014 to 2016 at Baystate Medical Center. In September 2015, an AMCS/CS team initiated a systematic care program based on integration of clinical, hemodynamic and echocardiographic profiling. Results From January 2014 to December 2016, time to device implant went from an average of 5.4 days to 3.4 days. The number of cases performed per calendar year increased from 8 in 2014 to 21 in 2016. Patient profiling, namely echocardiographic assessment, right heart catheterization and weaning trails with hemolysis surveillance, increased from 50% to 85%; 2014 and 2016 respectively. Mortality during this time trended down from 45% in 2014 to 33% in 2016. Lastly, involvement of advanced heart failure specialist increased yearly (20% in 2014 and 85% in 2016). Conclusion We aim to highlight the importance of a multi-disciplinary systematic approach to CS patients, involving both early recognition and intervention. The importance of timely invasive strategies requires expertise and coordination of care amongst cardiovascular specialties and front-line clinicians. Implementation of a multidisciplinary AMCS/CS team resulted in streamlined care and profiling of optimal patient selection allowing earlier intervention. Through longitudinal care, we were able to drastically increase the volume of patients cared for with earlier AMCS intervention, ultimately providing a trend towards mortality improvement in this descriptive study. Multi-center prospective registry data will help define clinical and socioeconomic profiles associated with myocardial recovery.