A 20-year-old woman presented with shortness of breath at her local community hospital. She had no medical history of cardiovascular conditions and an angiogram revealed no disease, but she was in cardiogenic shock with severe heart failure. The team placed an Impella CP device to stabilize her and contacted the UCSF transfer center.
“We made a shared decision with the referring center that it was safe to move her to UCSF, but it had to be done quickly due to complexities escalating from mechanical support,” said critical care cardiologist Connor O’Brien, MD, who leads the UCSF cardiogenic shock team.
UCSF has a rapid transfer protocol in place, which includes immediate access to a critical care cardiologist, expedited triage and a dedicated unit for patients transferring in for emergent care. “This is really important for patients experiencing cardiogenic shock because time-sensitive interventions need to be deployed,” O’Brien said. “We have a multidisciplinary approach to cardiogenic shock and a standard algorithm by which to activate the team and get the correct therapy in place as early as possible.”
Complications from giant cell myocarditis
When the patient arrived at UCSF, the cardiogenic shock team immediately determined that she required extracorporeal membrane oxygenation (ECMO) support. Invasive hemodynamics revealed small blood vessels, so the patient was placed on ECMO using grafts to mitigate potential vascular injury. This occurred within 12 hours of admission.
The team also performed a biopsy, and the patient was quickly diagnosed with giant cell myocarditis. The cardiogenic shock team includes Javid Moslehi, MD, chief of the UCSF Cardio-Oncology & Immunology Program, who initiated treatment with novel immunosuppressive techniques within 24 hours. “Having a cardio-immunologist who participates in shock care is very unique,” O’Brien said.
After five days, the patient’s left ventricular function normalized, allowing for ECMO decannulation and de-escalation of the Impella CP device. Because of rapid transfer to UCSF and early intervention by specialists, the patient recovered well and didn’t require a heart transplant.
Cardiogenic shock teams reduce mortality
In 2020, O’Brien led the creation of UCSF’s dedicated cardiogenic shock team, which includes critical care cardiologists, heart failure specialists, cardiac surgeons, interventional cardiologists, cardio-immunologists and specialized nursing staff.
According to nationally published data, the mortality rate for cardiogenic shock is typically 40 to 50%. In the UCSF cardiogenic shock team’s first year, the mortality rate was reduced to below 30%. “And the acuity of our patients is much, much higher than average,” O’Brien said.
Expanding access by coordinating care with hospitals statewide
In a project sponsored by the California Chapter of the American College of Cardiology, the team is working with hospitals throughout California to define and quantify hospital-level resources to care for patients admitted with cardiogenic shock. Through this effort, the goal is to identify care gaps and develop collaborations that improve care delivery at a state level.
“We’re actively performing outreach with other institutions to better understand existing resources,” O’Brien said. These include surgical resources, mechanical support, cardiac catheterization lab and ICU capabilities, transport systems, insurance payer mix and other factors. “We are working to operationalize in complex, decentralized environments. This takes a lot of pre-planning.”
Recently published data show that hospital networks delivering robust care coordination for cardiogenic shock can achieve similar outcomes regardless of whether the patient presents to a satellite center or a referral hub.
“We know that shock teams can have success beyond their walls,” O’Brien said. “We’re working to improve care for cardiogenic shock patients in California and beyond.”
To transfer a patient to UCSF
UCSF Adult Integrated Transfer Center
Phone:(415) 353-9166 | Fax: (415) 353-9172
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