Case Study: PCCS Care Pathway
This case study illustrates the importance of being prepared for post-cardiotomy cardiogenic shock (PCCS) in patients with comorbidities. The use of hemodynamic assessment in conjunction with a Heart Team approach allowed this patient to receive the appropriate level of hemodynamic support without delay.
A 61-year-old male with multiple comorbidities presented to the hospital with deep vein thrombosis (DVT). He had a severely reduced left ventricular ejection fraction (LVEF 20-30%) with significant multivessel disease and severe mitral regurgitation with pulmonary hypertension. A Heart Team—involving cardiology, cardiothoracic surgery, and cardiac anesthesia—discussed options and implemented a plan to help ensure the best outcome for the patient. In light of the patient’s known comorbidities, the team performed a pre-op hemodynamic assessment to help determine the pre-op and post-op course of care.
The patient was taken to the OR for coronary artery bypass graft (CABG) surgery and mitral valve repair. The surgical team was given clear direction to avoid using inotropes and vasopressors to assist the patient in separating from cardiopulmonary bypass. If PCCS necessitated the use of pharmacologic support, the surgeon would place an Impella 5.5® with SmartAssist® heart pump. The surgeon therefore proactively attached a 10mm Hemashield Platinum® graft onto the anterior ascending aorta for potential Impella 5.5 with SmartAssist implant.
The patient underwent successful CABG and mitral valve replacement. However, he then experienced PCCS and the surgeon proceeded with the Heart Team’s plan for direct aortic insertion of Impella 5.5 with SmartAssist heart pump. With Impella 5.5 with SmartAssist support, the patient was successfully separated from bypass with low doses of pharmacologic support (7.5 mcg/kg/min of dobutamine and 0.05 mcg/kg/min of Levophed) and he was transferred to the ICU. Levophed was discontinued within 4 hours of ICU admission and dobutamine was slowly weaned off overnight.
The patient was extubated on post-op day one, out of bed and sitting in a chair on post-op day two, and Impella was successfully weaned and explanted on post-op day three. The patient received a pacemaker prior to discharge and was sent home to recover.
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