Hackensack University Medical Center Optimizes Mechanical Circulatory Support Device Deployment with Significant Patient Recovery Outcome Gains
Proactive surgical axillary access and femoral bypass approaches lead to higher survival, fewer leg complications in cardiogenic shock patients
Hackensack University Medical Center has found complications with mechanical support in cardiac shock patients are reduced by 50% by applying proactive protocols regarding circulatory support device deployment and a team-based approach. How the device is deployed can make a huge difference for outcomes.
“Timing is critical with these patients,” Mark Anderson, M.D., Hackensack University Medical Center Cardiac Surgery chair, said. “As we say, ‘time in shock is time in shock.’”
The recent New England Journal of Medicine publication of the DanGer Shock trial showed Impella leads to higher survival at 180 days than standard care. Hackensack University Medical Center is an early adopter of Impella, and host to multiple clinical trials. Building on this experience, the team’s recent focus is Impella deployment protocol efficiency.
The team found that when cardiologists entered via the femoral artery in emergency cases, patients were often so sick that all arteries were affected, including those in the legs, which led to significant circulation issues.
Additionally, challenges with groin access points can arise due to the size of the device versus the size of the individual. A smaller person may have a 5-mm diameter femoral artery, versus a larger person with 6-8 mm femoral artery, which can exclude the use of some mechanical support devices without blocking blood flow to the legs.
“In an emergency situation, you may choose femoral access, but know that leg perfusion will be compromised,” Hackensack University Medical Center interventional cardiologist Haroon Faraz, M.D., said.
In severe cases, the team proactively assesses leg circulation before and after the procedure and immediately plans quick follow-up support with an external femoral-to-femoral bypass to stabilize the patient and allow the leg to be perfused, he said. If found to be blocked, the iliac artery can be ballooned and shunted, and the femoral bypass can serve as a back-up. Then, typically within 4 to 6 hours, the patient is transitioned to an axillary approach performed surgically by a vascular surgeon alerted at initial patient presentation.
When the team initially analyzed data in such cases, they found leg complications were the largest morbidity cause and the primary reason for upgrading to a surgically placed machine. With axillary device placement pre-planned as a quick follow-up procedure, groin complications decreased from 17% to 7%.
When they know a patient may need extra support, they prepare for insertion through the arm, which can push to 30 days if need be in many cases, whereas the groin inserted device can only support 3 to7 days.
“When a patient arrives in full-blown shock, with both sides of the heart affected and a breathing tube needed, three days of support is not enough. So, we’re already planning that additional support up front,” Kanika Mody, M.D., medical director, Hackensack University Medical Center Surgical VAD Program, said. In pseudo elective cases, they can take time to image the arteries and heart and enter surgically through the arm initially when a longer support timeframe is anticipated.
At Hackensack University Medical Center, 70% of cardiogenic shock patients have the support machine removed electively with some level of heart function recovery, and, of these, 60% go home with only medication support. The center now experiences double the level of recovery in patients and has shown that after a year on medical therapy, patient heart function elevates from 25 to 40%—the high end taking patients out of the range of sudden cardiac death risk and chronic heart failure status.
Learn more about innovative cardiovascular care at Hackensack University Medical Center.
