Brian O’Neill, MD, Associate Professor of Medicine at Temple University talks about how the Impella pump is improving outcomes for patients.
Interview conducted by Ivanhoe Broadcast News in August 2019.
It’s been 20 years. What took so long to get this? This is great.
O’NEILL: The challenges in treating patients that present with a heart attack and low blood pressure is many of them are critically ill. For a long period of time we didn’t have therapies to help support their blood pressure during these procedures. So within the last 10 years we’ve actually seen the development of multiple different devices, which can be placed through a very small incision in the skin that allow us to then support the patient’s blood pressure during the time where they’re most critically ill. And this has really allowed us to then apply these therapies to these specific patients who come in that have a heart attack and very low blood pressure.
On that timeline of when the heart attack happens, when is the patient in the most danger of the heart stopping?
O’NEILL: It can be a spectrum. But in the patients that are most critically ill, time really is critical. The ones that come in that are the sickest are certainly at risk of having loss of blood pressure completely and then suffering cardiac arrest. So this device will allow us to then support those patients and keep them stable during the procedure because what can sometimes happen is during the procedure to open the blocked artery, they can become very critical on the table and potentially suffer cardiac arrest. And so having this pump available to us will allow us to then treat them and decrease the chances of them having that cardiac arrest.
The EMTs are furnishing useful information to you to let you know that the patient’s going to hit the protocol. First of all what is the protocol?
O’NEILL: The protocol is really a combination of many different medical personnel. Early it is started in the point of contact, so that can really be through either emerging emergency medical services or through emergency department. When we as the interventional cardiologists are notified of these patients, we will then come evaluate them and see if they may potentially fit the protocol and really the protocol is nice because it’s very broad. It just is really all about looking at the numbers. So if we suspect a patient’s having a heart attack and we feel their blood pressure is low, we use a cutoff of less than 90 millimeters of mercury. We use that definition of what we term shock, and shock essentially just means low blood pressure. So if it’s a combination of a patient presenting with a heart attack and a patient having low blood pressure, then we use that information as someone that could potentially benefit from this protocol. The next steps are that we take them to the cardiac catheterization laboratory and we take some more measurements through a small catheter that’d be placed through a neck vein. And if we have confirmed the patient does have what we call term shock and is having a heart attack these are patients who may potentially benefit from this protocol. So we would want to try to enroll those patients in the protocol.
What is the time period generally prior to this and the time period now including this to keep their heart going?
O’NEILL: When we encounter a patient that is sick like this, time is everything and we try to move as rapidly as we can. One of the things that has challenged us for a long time in cardiology is that not being able to kind of help with the blood pressure. Even when we fix the arteries on the patients, they can suffer a poor outcome because their heart really never recovers from the initial stunning. We’re hoping that with this protocol, we can help prevent some of that stunning. If a patient is having a very severe heart attack, we are tasked with bringing the patient to the cath lab and having the artery open within 90 minutes. We really try to use that in the back of our mind as a time period to really make sure that they are having support during these sick times.
That’s the static thing where this goes in the vessel and you’re looking at the results, but your actual thing is fed through the artery right?
O’NEILL: That’s correct. We use a couple of different catheters when we’re treating these patients. The first one, the heart pump, goes through a catheter to be placed in the leg. And then we use another small catheter in order to place our balloons and stents that goes through one of the arteries. The wonderful thing about this protocol and the wonderful thing about these pumps is that this will allow the patient to be very stable during the time we’re working in the arteries and really allows us the benefit of not having to worry about trying to treat this artery in someone that’s having cardiac arrest. So it really kind of stabilizes things and allows us to take our time to make sure we do a good job, make sure the artery looks great afterwards, and we then can assess to see if they still need the pump because many times when we fix the artery we can take the pump out pretty quickly afterwards. Sometimes the heart is a little bit more stunned and may potentially need to have the catheter in for a little bit more of a prolonged period of time. Those are kind of the things we use. And we have in the protocol that we use, which is part of the national cardiac shock initiative, we have various defined criteria that allow us to determine, can we take the pump out? Do we leave the pump in? Or do we have to think about an alternative pump or even more pumps to help the heart out in those conditions?
How long does that on average stay in?
O’NEILL: Only about 24 hours.
So even after you get the stent in, you wait to pull that out and then do the stent?
O’NEILL: Many times we like to leave the pump in after a patient is very ill just because even after the stent goes in they can sometimes have episodes of low blood pressure that need to be managed. We want to try to avoid medications very powerful medications that artificially raise the blood pressure. We found that in the trial that these patients actually do worse than those patients that aren’t on these blood pressure medications. We’d like to try to use the pump as much as we can to support the heart during that really first critical 24 hours.
You said you’ve had five patients that you utilized this on.
O’NEILL: Correct.
The very first time that you did it, how exciting was that for you as an interventional?
O’NEILL: I remember the case very, very vividly because the patient was having an S T segment elevation MI, which on the spectrum of coronary disease is the most deadly type of presentation. And we got her to the cath lab. She was doing OK. But really very quickly after we started the blood pressure became extremely, extremely low. And I would have been very nervous. This patient would have suffered a cardiac arrest had I not had the pump to support her. So the first thing that we did is we put the pump in. Her blood pressure became very stable, and this allowed us then to complete the procedure without any challenges at all. We actually were able to take the pump out on the on the table there. We didn’t have to wait to take it out in 24 hours. And she really did remarkably well – really kind of recovered – almost completely recovered her heart function, was able to leave the hospital after a few days. If you take this particular patient and you treat her the old way we would treat her, there’s a really high likelihood that she would have not made it through the hospitalization, or if she did, she would have been in hospitalization for a very long time, had a lot of different complications, and I don’t think would have been discharged in such a great shape as she was being able to have the pump.
Walk us through how you insert it, where it goes in, and what happens when that hook gets in there.
O’NEILL: The first thing that we do is by using ultrasound, we put a small catheter into the leg. This allows us to then assess the diameter of the vessel, the femoral artery, to see if the femoral artery is big enough. That’s one of limitations of the protocol and of this method of treating patients is that the arteries have to be big enough to allow the pump to go in. If it looks like it’s big enough, what we’ll do then is we will put in a slightly bigger sheath. We use a catheter to place a small wire across the aortic valve into the left ventricle which is the main pumping chamber of the heart that then allows us to thread the pump over the catheter into the heart and then and then we turn the pump on.
So 40 institutions are now using this. Let’s say a guy sitting in Fresno in his easy chair and there’s nothing in Fresno – when can he expect it?
O’NEILL: Well any interested hospital is encouraged to join us in this initiative. We hear a lot of times that this is a coalition of the willing. It’s really a coalition of doctors who want to improve outcomes for patients. We want to do better, however we can, in this condition. If you go online, you can find information about the shock initiative. And more sites are being recruited every day. For patients themselves who are interested, they can also go online and get information about this to see what the closest hospital is around them in case something happens where they may need to urgently be treated. The reason it’s important for us to study this protocol and use it is that this condition and these patients are going to be coming to really all hospitals in the United States. There’s really no hospital that will not get experience with these patients. So the more hospitals that can be involved, the more hospitals we can study with this, I think it’s gonna be really important in terms of us being able to improve outcomes for patients.
END OF INTERVIEW
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