Role of RHC during Hemodynamic Support in CGS Should every MCS patient have a RHC? Role of RHC during Hemodynamic Support in CGS Daniel Burkhoff MD PhD Director, CHF, Hemodynamics and MCS Research Cardiovascular Research Foundation Adjunct Associate Professor of Medicine Columbia University

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Grant/Research Support Consulting Fees/Honoraria Abiomed Heartware/Medtronic

Role of RHC during Hemodynamic Support in CGS Should every MCS patient have a RHC? Role of RHC during Hemodynamic Support in CGS When the indication for MCS is hemodynamic compromise, the answer is: Most likely YES

PAC Measurements mVO2 Sat CO / CI PVR SVR CPO PAPi DO2 RA / CVP RV PA PA Occlusion

Physiological Rationale for Use 6/12/2018 Physiological Rationale for Use Clinical evaluation may be misleading especially in unstable patients with rapidly changing hemodynamics1 Pulmonary Artery Catheters (PAC) allow for bedside measurement of major determinants of cardiac performance (preload, afterload, CO) supplying additional data for clinical decision making2 Connors AF et al., NEJM 1983 Gorlin R et al., NEJM 1977

Objectives of Use Diagnosis: Guide Therapy: 6/12/2018 Objectives of Use Diagnosis: Assess fluid status Assess adequacy of oxygen delivery (CI, CPI) Assess pulmonary vascular Guide Therapy: Diuretics / Fluid administration Inotropes Vasodilators / Pressors VAD Settings Provide prognostic information

6/12/2018 PAC Under Fire !! Despite all of the advantages of the PAC, multiple studies have shown no benefit or an increased risk of morbidity or mortality associated with its use. An intense assessment of its application in non-acute and non-shock decompensated heart failure has been provided by the ESCAPE trial1, that showed an overall neutral impact of PAC therapy over therapy guided by clinical evaluation and judgment alone. Prior results DO NOT apply to cardiogenic shock and DEFINITELY NOT in the setting of MCS2-4 Binanay C et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005 Oct 5;294(13):1625-33 Cohen MG et al. Pulmonary artery catheterization in acute coronary syndromes: insights from the GUSTO IIb and GUSTO III trials. Am J Med. 2005 May;118(5):482-8 Zion MM, et al. Use of pulmonary artery catheters in patients with acute myocardial infarction. Analysis of experience in 5,841 patients in the SPRINT Registry. Chest. 1990;98:1331–1335. Connors AF et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA. 1996;276:889–897

Trottier and Taylor. New Horiz 1997;5:201-206 Physicians’ attitudes toward and knowledge of the pulmonary artery catheter: Society of Critical Care Medicine membership survey. Trottier and Taylor. New Horiz 1997;5:201-206 33% of respondents incorrectly identified PA occlusion pressure on a clear tracing

Recent studies highlighting usefulness of RHC in heart failure and MCS

JACC Heart Fail. 2016 Mar;4(3):208-17. 34 STABLE, Out-patient LVAD Patients 13 HVAD (avg 2700 rpm) 21 HMII (avg 9200 rpm) Average ~57 yo Average ~500 days after implant ALL seemingly well compensated Parameters Measured: RHC 2D/3D Echocardiography

RPM-Dependence of PCWP Despite appearing well compensated, many patients have very high PCWP HVAD HMII Step 0: 2300 8000 rpms 1 Step: 100 400 rpms HVAD HMII

Despite appearing well compensated, many patients have very high CVP RPM-Dependence of CVP Despite appearing well compensated, many patients have very high CVP HVAD HMII Step 0: 2300 8000 rpms 1 Step: 100 400 rpms HVAD HMII

JACC Heart Fail. 2016 Mar;4(3):208-17. Conclusion In patients supported by durable MCS, it is typically not possible to assess fluid status based on clinical evaluation and judgment

PAC Use during acute MCS Currently available data and guidelines are inadequate to address the need for PAC use during MCS Guidelines should address: When to use PAC How to use the information derived from PAC In absence of society-endorsed guidelines, sound physiological reasoning prevails

Example: Patients on ECMO Pressure-Volume ↑ Afterload ↑ Preload AoP and LVP ↑ AoP ↑ LVP

OPTIMAL MANAGEMENT REQUIRES KNOWLEDGE OF PCWP Patient on ECMO PCWP rises substantially in many patients on ECMO Waiting for appearance of pulmonary edema on CXR can significantly delay delivery of appropriate therapy and contribute to additional morbidity Earlier recognition of need to unload the LV may increase rates of recovery Even in the absence of pulmonary edema, ECMO does not unload the LV To the degree that LV unloading contributes to recovery, PAC can expedite adjustment of therapy OPTIMAL MANAGEMENT REQUIRES KNOWLEDGE OF PCWP

ECMO + Impella (ECPELLA) ↑ Afterload ↑ Preload AoP LVP

Two Patients with Similar Clinical Presentations and Responses to IMPELLA HR 110 ABP: ~70/45 CVP ~10 Lactate elevated (~4 mEq/L) Failure of inotropic therapy IMPELLA CP implanted Good position confirmed Flow initially good Low flow/suction alarms start

RHF due to RV Dysfunction Two Patients with Similar Clinical Presentations and Responses to IMPELLA Patient 1 Patient 2 CVP 18 mmHg PA 57/30 (39) mmHg PCWP 20 mmHg CO 2.5 L/min PVR 7.6 Wood PAPi 0.95 CVP 15 mmHg PA 20/9 (12) mmHg PCWP 5 mmHg CO 2.5 L/min PVR 2.8 Wood PAPi RHF due to elevated PVR  Vasodilator therapy RHF due to RV Dysfunction  RVAD

PAC Use during MCS What about “wait and see how things go” approach?

RHC-guided Stepwise Treatment CVP – PCWP Diagram CI <2.2 ≥2.2 1. Impella CP 3. Diuresis 2. Impella RP

Summary and Conclusions Retrospective and randomized studies show no significant harm or benefit of indiscriminant PAC use during circulatory shock in ICU settings No study has evaluated the use of PAC-specific data to drive a treatment protocol known to improve outcomes Prior studies question consistent education in the interpretation of PAC tracings Knowledge of whether the tracing reliably measures intended pressures and flows is critical to success No study has ever evaluated the utility of PAC in patients receiving MCS for CGS At least one recent study shows limitation of clinical assessment of volume status in stable patients undergoing long-term MCS No specific guidelines

Summary and Conclusions Use of PAC in acute pLVAD – CGS patient my hasten proper diagnosis and guide choice of therapy time is critical in CGS Use of PAC may guide optimization of therapy, particularly during MCS, to restore normal hemodynamics and physiology Fluid status (CVP, PCWP, Hb oxygenation in lungs) PVR Early detection of RHF and early intervention Use of PAC may aid during weaning process Hemodynamics are even more complex during ECMO and Biventricular support Extra care during prolonged PAC use: Infection Bleeding Thrombus Vascular damage Arrhythmias Etc..