“Do you believe anything is possible?” asks Shelley Hall, MD, FACC, FHFSA, FAST, in her presentation at the 2021 Heart Failure Society of America (HFSA) scientific meeting. “In the cardiogenic shock world, you have to believe that,” she emphasizes, noting that if we let worries about risk and cost drive the science behind cardiogenic shock, “then we’re going to have a lot of patients that won’t be here next year.”

Dr. Hall, chief of transplant cardiology and mechanical support/heart failure at Baylor University Medical Center, discusses the challenges of creating trials to advance the science of cardiogenic shock. “The reality is that not all shock is created equal,” she explains, describing the differences between cardiogenic shock following acute myocardial infarction (AMI) and shock in chronic heart failure patients.

Dr. Hall then presents lessons learned over the past few years to improve shock survival. “The first is hemodynamic monitoring,” she states, to provide “real hemodynamics,” including pulmonary artery pulsatility index (PAPi) and cardiac power output (CPO). “These are things that are now very, very important in ascertaining what ventricles are involved, how bad those ventricles are, and prognosis.”

“The other thing we know,” she emphasizes, “is whatever device you’re going to use, use it early.” And finally, she focuses on the importance of shock teams. “When you put organized protocols in place, you’re going to improve your outcomes.”

Dr. Hall then presents a case study to illustrate why all of this is important. Dr. Maurice Williams, age 50, was undergoing invasive, open-abdomen, elective spine surgery when he suffered cardiac arrest. After 30 minutes of CPR, an interventional cardiologist agreed to take the case to the cath lab. The patient had severe multivessel disease and the cardiologist opened every vessel that he could and placed an Impella CP® following the procedure. Just 24 hours later the patient was off all pressors and had recovered pulsatility and improved EF (EF 50-55%). Impella was removed 24 hours after that.

“He was very lucky,” Dr. Hall recounts. Lucky his spine surgery took place in a combined spine and heart hospital. Lucky the cardiologist agreed to take him to the cath lab. Lucky to have full support options to get him through the procedures and enable heart recovery. “We should not be relying on luck with these patients,” Dr. Hall states. “We should be developing proper science.”

Dr. Hall concludes her presentation with a call to action. “We need a lot more real-world evidence to know what to do and when to do it. We need appropriately designed trials. And we need buy in among all areas of cardiology and intensive care medicine on the importance of real hemodynamics, dissecting out the etiologies, and institutional structure formation. And in reality, we do need to know and learn which shock patients we can save and recover and ones we can’t.”