So with that, we'll go ahead and transition to our first speaker, and I'll have Dr. Ludmere share his slides. So Dr. Jonah Ludmere is a critical care cardiologist at Massachusetts General Hospital. He received his medical degree from the Perelman School of Medicine at the University of Pennsylvania, as well as completing his residency at UPenn and the Children's Hospital of Philadelphia, cardiology fellowship at the University of Maryland, and critical care fellowship at Stanford University Medical Center, and he'll be speaking on the management of cardiogenic shock in pregnancy. Thank you, Dr. Ludmere. Thank you, Dr. Park. I'm delighted to be here this evening. I'm going to give a brief highlight of the management of cardiogenic shock in pregnancy. So the key objectives for this brief talk are to discuss the etiology of cardiogenic shock in pregnancy, highlight an approach to management of shock, and then briefly review the use of mechanical circulatory support in the peripartum period. So first, in terms of the etiologies of cardiogenic shock in pregnancy, by far the most common reason is peripartum cardiomyopathy, followed by a combination of amniotic fluid embolism, PE, MI, and then a whole slew of pre-existing cardiac disease, including valvular heart disease and pre-existing cardiomyopathy. So I just want to highlight two important ones. First, peripartum cardiomyopathy, since it's the most common reason for cardiogenic shock. And this is an idiopathic cardiomyopathy that presents typically towards the end of pregnancy and in the first couple months post-delivery. The incidence in the U.S. ranges between 1 in 1,000 to 1 in 4,000, but it's actually more common outside of the U.S. And one key point is that the initial LVEF with the initial diagnosis is a predictor of adverse outcomes. Generally, patients who have an EF greater than 30% at the initial diagnosis tend to have better outcomes. I also want to briefly highlight amniotic fluid embolism, or AFE, which is caused by an abnormal maternal response to fetal tissue, typically at the time of delivery. And the triad to recognize is hypoxia, sudden hemodynamic collapse, and coagulopathy. Unfortunately, there's no absolute management of this except for supportive care. And the outcomes vary, but mortality can be significant. Let me give a brief overview of the best study that I've found to date that kind of highlights cardiogenic shock in pregnancy. And this is using the National Inpatient Sample. And it incorporated over 53 million pregnancy-related hospitalizations, of which just over 2,000 were complicated by cardiogenic shock. The mortality in this cohort was about 19%. And here's a graph looking at maternal admissions for cardiogenic shock over time. And as you can see with the black line, the incidence of C-shock has been increasing, as has the use of MCS, noted in the red dotted line here. Mortality rate for cardiogenic shock over time has slightly been decreasing. The key findings from this National Inpatient Sample survey were that 50% of the cardiogenic shock cases were associated with peripartum carmiopathy. And 80% of those in the postpartum period were actually associated with peripartum carmiopathy. One third of all the patients with C-shock received some form of MCS. And perhaps the key takeaway here were that women who received early MCS, so within four to five days, had lower mortality compared to those that had later deployment of MCS. So now let's highlight an approach to C-shock. This is a nice figure from the Journal of American Heart Association. And the key things here are the initial diagnosis, using your history, physical labs, hemodynamic assessment, in conjunction with a cardiac OB team to help us manage cardiogenic shock. So coming here in the unstable or shock picture here, we're doing what we do with any form of cardiogenic shock, right? We're optimizing preload, optimizing oxygenization, working with inotropes, vasopressors, and considering MCS when needed. And of course, working with our MFM colleagues to figure out the best management for delivery. I always like looking at this bedside checklist from Sky, because it reminds us to look at the exam, markers of perfusion, and the hemodynamics. And what I want to note here is the strong recommendation for PA catheter, because this can help define the hemodynamic profile and help us guide therapy and select the appropriate therapy and decide whether we need early mechanical surgatory support. So my two real big takeaways here are we need to make an early diagnosis using echo, using a PA line, and manage as we do all forms of cardiogenic shock and assess the response early to decide if we need MCS. Let me highlight a couple of the studies we have for MCS in the peripartum period, and there aren't that many. This is perhaps the largest case series of impella use in C-shock in the peripartum cardiomyopathy population, and this is a case series from the U.S. and Germany. A total of just 15 patients who required impella, 27% needed to be upgraded to VA ECMO, and survival was quite good in this population. What about ECMO? This is an ELSO registry study of peripartum cardiomyopathy patients, of which 88 were cannulated for ECMO, and survival was also pretty good, 64%. Of those who were cannulated during CPR, 60% survived, so pretty good survival when we compare it to all comers, especially when it comes to eCPR. This is a figure looking at the use of ECMO and survival over time from the study I just showed you, and what we're seeing here is survival increases, but we're also using more ECMO, and this is perhaps the largest retrospective systematic review that I found. 358 peripartum patients who received ECMO, and this is all ECMO, VV and VA. We see here about 41% were VA ECMO, and of those 45, which was the highest percentage for VA ECMO, was for peripartum cardiomyopathy. Survival was excellent, 75% at 30 days, 74% at one year. Fetal survivor was about 65%, and these were the indications. The number one was ARDS, so primarily VV ECMO. We see peripartum cardiomyopathy, AFV. We're going to be hearing about PE in a bit, and I just want to highlight, I know this is part of the first webinar, but the importance of working together to make these decisions with a cardiac OB team in conjunction with a shock team, and I think this is imperative when we come to pregnant women in cardiogenic shock. This is a figure from the University of Utah, and how they work their cardiogenic shock team is similar to our team at MGH. You incorporate a heart failure cardiologist, CT surgeon, interventionalist, and a cardiac intensivist, and what they demonstrated is over time when they use a shock team versus a control cohort with no shock team, survival was better. I just want to conclude to put this all together with a case from our Heart Center ICU. It's a patient I recently took care of. It's a 32-year-old G4P3 woman who is at 16 weeks gestation. She had been diagnosed with a recent dilated non-ischemic cardiomyopathy, unclear ideology. She was brought to the operating room with cardiac anesthesia, MFM, and this was a decision made with her, her family, and the cardio OB team, and she underwent an elective D&E. Unfortunately, she suffered a PA arrest at the time. She had become profoundly hypoxic and had sudden cardiovascular collapse. She was cannulated for ECMO. This is her TE during cannulation. This is a mid-esophageal four chamber, and we see that there is severe biventricular dysfunction, and there's evidence of thrombus, both in the right atrium, in the left ventricle, and the left atrium. Unfortunately, this patient suffered severe multi-organ dysfunction, and she had embolized to multiple organ systems. So, the takeaways from this brief overview are that, you know, making a diagnosis of cardiogenic shock early is key. Use your hemodynamic assessment up front. Consider early use of MCS because we know that early use is associated with improvement in outcome, and fortunately, survival in the peripartum period tends to be quite good. And of course, all of this, all these decisions should be done in collaboration with our shock team and the cardio OB team. Thank you.

cardiogenic shock

pregnancy

peripartum cardiomyopathy

mechanical circulatory support

multidisciplinary approach