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

2. 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 “I’m Not Dead Yet”: Presentation Jeffrey F. Bleakley, University of Rochester

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

4. 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 “I’m Not Dead Yet”: History Jeffrey F. Bleakley, University of Rochester

5. 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 “I’m Not Dead Yet”: Physical Jeffrey F. Bleakley, University of Rochester

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

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

8. RCA: occluded

9. 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 “I’m Not Dead Yet”: Management Jeffrey F. Bleakley, University of Rochester

10. LAD: severely diseased

11. Severe disease

12. 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 “I’m Not Dead Yet”: Management Jeffrey F. Bleakley, University of Rochester

13. PTCA

15. Final angiogram

16. 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 compressionsFull ACLS protocol was followed including 5 minutes of chest compressions SCAI C3 Summit Chicago May 12-13, 2006 “I’m Not Dead Yet”: Management Jeffrey F. Bleakley, University of Rochester

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

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

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

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

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

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

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

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

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

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

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

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

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

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