Optimizing AMICS Patient Care Prior to Leaving the Cath Lab

It is critical for interventional cardiologists to optimize care of patients with acute myocardial infarction cardiogenic shock (AMICS) before leaving the cath lab. Amir Kaki, MD, FACC, FSCAI, of Ascension St. John Hospital in Detroit emphasizes this in his June 2022 presentation at a Coronary Artery and Myocardial Protected PCI (CAMP PCI) educational event on cardiogenic shock and high-risk PCI. Dr. Kaki discusses best practices and practical patient management considerations pertaining to hemodynamics, medications, MCS devices, access, limb perfusion, and use of sodium bicarbonate in the Impella® purge solution.

First, Dr. Kaki reviews his institution’s sheath management strategies, which include retaining the Impella® peel-away sheath if there’s flow around the sheath to mitigate bleeding, and returning to the cath lab for sheath removal where options are readily available to handle bleeding complications.

Dr. Kaki discusses strategies for identifying, preventing, and treating acute limb ischemia with specific emphasis on options for pre-emptive antegrade access. He also addresses strategies for what to do if your completion angiogram is occlusive. “The first thing I would do,” he states, “is peel away the sheath, understanding there is risk to the peeling away of the sheath.” He reviews the steps for removing the peel-away sheath and advancing the repositioning sheath. He then briefly discusses bypass techniques including external ipsilateral bypass. He also presents a limb perfusion checklist for assessing, preventing, and treating limb ischemia.

Dr. Kaki concludes his presentation by discussing two recent developments. He introduces the ultra-thin-wall CP sheath, which is under development. It is a non-peel-away sheath with high-flow sidearm and stopcock, hydrophilic long taper dilator, and an outer diameter that is smaller than the Impella CP® sheath to help optimize management of bleeding and ischemia without the need for the peel-away sheath. He also explains that as of May 2022, sodium bicarbonate is approved for use in the Impella purge solution for patients who are intolerant to heparin or in whom heparin is contraindicated (e.g. due to heparin-induced thrombocytopenia or bleeding). Instead of using heparin, clinicians can use a purge solution of 5% dextrose in water (D5W) with 25 or 50 mEq/L sodium bicarbonate. This can help address the complexity of managing a patient’s total heparin dose (systemic heparin + heparin in the purge fluid) while maintaining a sufficiently high purge solution pH to keep the Impella motor gaps free of blood protein deposits that can accumulate with the acidotic pH of D5W alone.