Shelley Hall, MD: The Right Time for Cardiogenic Devices

Doctors treating patients suffering from cardiogenic shock have many devices to choose from to help stabilize the patient. But when time is of the essence, how do they decide which device is appropriate for the patient?

During the Heart Failure Society of America (HFSA) 2019 Scientific Sessions in Philadelphia, PA, Shelley Hall, MD, chief of transplant cardiology, mechanical support, and advanced heart failure at the Baylor University Medical Center explained in an interview with MD Magazine® how doctors can best decide at the moment when and how to use a cardiogenic device.

MD Mag: When should doctors use cardiogenic shock devices for temporary mechanical support?

Hall: The problem with this patient population is they often come in crisis, they're on a ventilator, you can't talk to them, you don't know them, that you have no idea what their

psychosocial situation is, what their other comorbidities are. Sometimes you're just dealing with a patient in shock and especially those outside of the heart failure community they just kind of get a myopic view, they go in there and they access the patient and throw in a device.

The heart failure community because we evaluate patients for advanced therapies all the time and understand to look for those issues, will check some of that out first. We will utilize an IV medication, will place a Swan(Ganz) to understand the hemodynamics of the patient and check out and see where are we potentially going to go after this episode of shock. If we're able to resuscitate him, where are they going to go if the only option is recovery because they're not options for advanced therapies like heart transplant or LVAD (left ventricular assist device) that may limit the devices that we utilize to less expensive options or less involved drastic options since they don't have an escape hatch so to speak. In addition, if this is a situation where we think recovery is incredibly low and they have no escape hatch, then we need choose not to use any devices and just be palliative in our approach to that patient.

MD Mag: What is the most important advice you would give for how doctors can use their best judgement when making these decisions?

Hall: I think that it's important not to get consumed in the crisis mode immediately and run to your favorite toy and throw it in. I think it's important to take a breath, take a step back, evaluate the patient. You must have hemodynamics on these patients, you have to place a swan. We're still fighting resistance to the PA catheter, you need that information. One it can help you decide what the best device is if needed and second you can often imagine that this wasn't cardiogenic in the first place and therefore the whole external appearance of the patient may lead you down that pathway but you may find that you're ultimately incorrect. So, placing the swam utilizing your vasopressors and inotropes for that brief period of time where you gather the right data, find out about the patient and then choose the best device if they

need a device for that particular patient.