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Cardiogenic Shock ……………………….and Then Some

“I’m Not Dead Yet”. Cardiogenic Shock ……………………….and Then Some. SCAI C3 Summit Chicago May 12-13, 2006. Jeffrey F. Bleakley, University of Rochester. “I’m Not Dead Yet”: Presentation.

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Cardiogenic Shock ……………………….and Then Some

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  1. “I’m Not Dead Yet” • Cardiogenic Shock ……………………….and Then Some SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  2. “I’m Not Dead Yet”: Presentation • 51 year old man with 45 minutes of chest pain associated with nausea, lightheadedness, and diaphoresis after lifting a sump pump SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  3. “I’m Not Dead Yet”: History • HTN • Hyperlipidemia • Strong family history of CAD • Current smoker SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  4. “I’m Not Dead Yet”: History • Presented to Strong Memorial Hospital via EMS • Noted to be diaphoretic and hypotensive with continuing chest pain SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  5. “I’m Not Dead Yet”: Physical • Cool, clammy and diaphoretic • Alert and oriented • JVP 12 cm above RA • Rales at the bases bilaterally • No murmurs SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  6. ECG SCAI C3 Summit Chicago May 12-13, 2006 SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  7. “I’m Not Dead Yet”: Management • Given ASA, plavix, integrelin • Dopamine started for hypotension • Taken emergently to the cath lab SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  8. RCA: occluded

  9. “I’m Not Dead Yet”: Management • Blood pressure drops and patient becomes bradycardic after RCA injection. • Pacemaker placed in anticipation of left coronary intervention. SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  10. LAD: severely diseased

  11. Severe disease

  12. “I’m Not Dead Yet”: Management • Discussed surgical approach, but less than enthusiastic response. • Dopamine continued and titrated • Patient intubated for respiratory decompensation • IABP placed. SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  13. PTCA

  14. PTCA

  15. Final angiogram

  16. “I’m Not Dead Yet”: Management • Patient hypotensive and bradycardic requiring pacing • Epinephrine and neosynephrine were given for blood pressure support • Full ACLS protocol was followed including 5 minutes of chest compressions SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  17. “I’m Not Dead Yet”: Management • Finally, a 5 mg bolus of epinephrine was given • Blood pressure and heart rate improved • Patient stable enough for transport • No evidence of VSD, MR or free wall rupture by echo; severely reduced LV function. SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  18. “I’m Not Dead Yet”: Management • Admitted to the CCU • Became progressively more unstable • Continued inotropic support • Had BIVAD placed in the early hours of the morning • Good urine output, followed commands, LFT’s normal the following day SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  19. “I’m Not Dead Yet”: Hospital Course • Cardiac transplantation performed on 9/27/05 • No signs of rejection • Patient discharged home in stable condition 10/14/05 • Continues to do well SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  20. “I’m Not Dead Yet”: Follow-up • Patient is in a band and is actively involved in local fundraisers for the cardiac transplant program. SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  21. “I’m Not Dead Yet”: Take home points • SHOCK trial • REMATCH trial • Don’t give up!!!! SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  22. “I’m Not Dead Yet”: SHOCK trial • Patients were randomized to emergency revascularization (n=1520 or medical stabilization (n=150 • Primary endpoint was mortality at 30 days • Secondary endpoint was mortality at 6 months SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  23. “I’m Not Dead Yet”: SHOCK SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  24. “I’m Not Dead Yet”: SHOCK SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  25. “I’m Not Dead Yet”: SHOCK SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  26. “I’m Not Dead Yet”: REMATCH • Patients were randomized to receive a left ventricular assist device (n=68) or optimal medical therapy (n=61) • Improved survival • Improved quality of life SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  27. “I’m Not Dead Yet”: REMATCH SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  28. “I’m Not Dead Yet”: REMATCH SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  29. “I’m Not Dead Yet”: REMATCH SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

  30. “I’m Not Dead Yet”: Take Home • DON’T GIVE UP !!!!!!!!!!!!!!!! SCAI C3 Summit Chicago May 12-13, 2006 Jeffrey F. Bleakley, University of Rochester

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