Is that "pulmonary hypertension" on the echo report actually driving your patient's shock, or is it just along for the ride? 

In this episode of SoCCC Pre-Rounds, Dr. Anthony Carnicelli is joined by Dr. Manreet Kanwar, an internationally recognized expert in pulmonary hypertension, cardiogenic shock, mechanical circulatory support, advanced heart failure, and heart transplantation, for a practical discussion on managing pulmonary hypertension in the cardiac intensive care unit. Together, they explore how clinicians can move beyond simply recognizing elevated pulmonary pressures to identifying the underlying disease process driving a patient's deterioration.

Dr. Kanwar explains why pulmonary hypertension should be viewed as a hemodynamic finding rather than a standalone diagnosis and why understanding its effect on the right ventricle is central to caring for critically ill patients. The conversation covers early bedside assessment, optimizing preload, the challenges of respiratory support, vasopressor selection, and the careful use of temporary mechanical circulatory support. Throughout the discussion, he emphasizes protecting the right ventricle while treating the underlying cause of pulmonary hypertension.

Whether you're admitting a patient with decompensated pulmonary hypertension or managing acute right ventricular failure overnight, this episode provides a thoughtful framework for approaching one of the CICU's most challenging patient populations.

Key Takeaways

• Pulmonary hypertension is a hemodynamic finding that requires identifying and treating the underlying cause.

• Right ventricular function should guide bedside assessment and management decisions in critically ill patients.

• Optimal preload is patient-specific and should be individualized rather than managed with blanket rules.

• Mechanical ventilation can worsen right ventricular failure and should be approached with caution.

• Norepinephrine and vasopressin are preferred vasopressors for hypotensive patients with pulmonary hypertension, while phenylephrine is generally avoided.

• Temporary mechanical circulatory support requires a clear exit strategy before implantation.

In This Episode

• [00:00] Introduction

• [01:37] Defining pulmonary hypertension 

• [04:20] Evaluating the critically ill patient with pulmonary hypertension

• [06:41] Right ventricular failure and preload management

• [09:46] Respiratory support and the risks of mechanical ventilation

• [13:26] Vasopressors and temporary mechanical circulatory support

• [17:44] Final clinical pearls for intensivists

• [19:11] Closing remarks 

Notable Quotes

• [02:49] "Pulmonary hypertension in itself is not a single disease. It is a hemodynamic finding. The key is to figure out the why." — Dr. Manreet Kanwar

• [11:13] "If you let the patient be very hypoxic or hypercarbic or wait till they're very acidotic to do something about it, this RV will just give out." — Dr. Manreet Kanwar

• [14:31] "When in doubt, use Levophed. Norepinephrine is always the drug of choice in all circumstances, period." —Dr. Manreet Kanwar

• [16:00] "Putting devices in is easy. It's the art of taking them out that becomes very, very tricky." —Dr. Manreet Kanwar

• [19:01] "Go forth and protect the RVs." — Dr. Manreet Kanwar

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Manreet Kanwar

• https://biologicalsciences.uchicago.edu/faculty/manreet-kanwar-md

• https://www.linkedin.com/in/manreet-kanwar-aa9897aa

Dr. Anthony Carnicelli

• https://www.soccc.org/

• https://www.linkedin.com/in/anthony-carnicelli-926a0b88/

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

What if a heart transplant patient doesn’t look like they’re in cardiogenic shock, but their graft is quietly failing?

In this episode of SoCCC Pre-Rounds, host Dr. Balim Senman sits down with Dr. Shashank Sinha, advanced heart failure and transplant cardiologist, Director of the CICU at Inova Heart and Vascular Institute, and co-chair of the SoCCC Research Council, for a practical discussion on recognizing, diagnosing, and managing acute graft dysfunction and heart transplant rejection.

Designed for residents, fellows, intensivists, and CICU teams, this episode explores why rejection should never be considered in isolation. Dr. Sinha emphasizes maintaining a broad differential that includes infection, tamponade, pulmonary embolism, mixed shock, and other causes of graft dysfunction.

The conversation covers the unique physiology of the denervated transplanted heart and why significant hemodynamic compromise may develop before hypotension. Dr. Sinha discusses the limitations of troponin and BNP, the importance of lactate and end-organ function trends, and the role of physical examination, point-of-care ultrasound, invasive hemodynamics, and endomyocardial biopsy.

The episode also breaks down the critical first hour of management, when empiric steroids may be appropriate before biopsy, how to approach simultaneous concern for infection and rejection, and the differences between acute cellular and antibody-mediated rejection. Advanced therapies including plasmapheresis, IVIG, immunomodulatory treatment, and temporary mechanical circulatory support are also discussed.

Key Takeaways

• Acute rejection is only one potential cause of graft dysfunction, so a broad differential is essential.

• Heart transplant recipients can develop significant shock before becoming hypotensive.

• Lactate, renal function, urine output, and tissue perfusion trends may be more informative than isolated cardiac biomarkers.

• Endomyocardial biopsy remains the gold standard for diagnosing transplant rejection.

• Stabilization, diagnostic evaluation, and empiric treatment may need to happen in parallel.

• Early involvement of transplant and multidisciplinary shock teams is critical.

In This Episode

[00:00] Introduction

[01:15] Meet Dr. Shashank Sinha

[01:59] Post-transplant case presentation

[02:52] Differential diagnosis for graft dysfunction

[03:33] Timing and risk of rejection

[04:38] Concerning clinical presentations

[06:24] Cardiac denervation

[08:05] Diagnostic evaluation and lab work

[10:33] Imaging and invasive hemodynamics

[11:47] The first hour of management

[13:54] Infection vs. rejection

[14:49] Types of rejection and treatment

[17:00] Advanced therapies and mechanical support

[19:19] Assessing graft recovery

[21:09] Key takeaways

[22:21] Closing remarks

Notable Quotes

[01:45] “Graft dysfunction and transplant rejection really reflect the true multidisciplinary nature of cardiac critical care, and this is one of the most treatable causes of cardiogenic shock if recognized early.” — Dr. Shashank Sinha

[05:47] “One mistake that I do see commonly is waiting for transplant patients to become hypotensive before we get very worried.” — Dr. Shashank Sinha

Resources and Links

Become a member:

https://www.soccc.org/subscribe

Dr. Shashank Sinha

https://www.inova.org/doctors/shashank-s-sinha-md

https://in.linkedin.com/in/dr-shashank-sinha

Dr. Balim Senman

https://www.linkedin.com/in/balim-senman-7561436b/

https://x.com/BalimSenmanMD

https://www.soccc.org/

Supported By

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

How do you choose the right vasoactive medication for a patient in cardiogenic shock? In this episode of SoCCC Pre-Rounds, hosts Dr. Anthony Carnicelli and Dr. Elliott Miller sit down for a practical, high-yield discussion on vasopressors, inotropes, and the real-world decision-making behind vasoactive medication management in the CICU.

Designed for residents, fellows, and ICU teams, this episode breaks down the pharmacology, clinical evidence, and bedside application of commonly used vasoactive agents including norepinephrine, dopamine, epinephrine, vasopressin, phenylephrine, dobutamine, and milrinone.

Dr. Carnicelli emphasizes a stepwise approach to vasoactive medication management: first understanding the pharmacology and intended physiologic effects, then learning how to apply those principles clinically in complex shock states. The conversation explores the limitations of existing cardiogenic shock data, including the aging SOAP II trial and the landmark DOREMI trial comparing milrinone and dobutamine.

The discussion also dives into nuanced scenarios such as LVOT obstruction, severe aortic stenosis, pulmonary hypertension, arrhythmogenic shock, and escalating vasopressor requirements that may signal the need for mechanical circulatory support.

Packed with practical teaching pearls and candid reflections from the CICU, this episode offers a thoughtful framework for approaching vasoactive medications beyond algorithms and dogma. Whether you are pre-rounding before sunrise or managing a crashing patient overnight, this episode delivers actionable insights you can apply immediately at the bedside.

• Norepinephrine remains the preferred first-line vasopressor in most cardiogenic shock patients.

• Vasopressin is generally avoided in low-output cardiogenic shock due to pure vasoconstrictive effects.

• Pulmonary hypertension and arrhythmogenic shock may be scenarios where vasopressin is helpful.

• DOREMI demonstrated no major efficacy or safety differences between milrinone and dobutamine.

• Vasoactive medication management is often more art than science.

• [00:00] Introduction 

• [01:51] A two-step approach to teaching vasoactive meds

• [03:30] The SOAP II trial: Norepinephrine vs. dopamine

• [06:41] Epinephrine as a first-line agent

• [08:19] When to avoid norepinephrine

• [09:57] Using vasopressin in cardiogenic shock

• [12:32] Phenylephrine in right heart failure

• [13:48] The DOREMI trial: Milrinone vs. dobutamine

• [17:32] Final thoughts and interdisciplinary approaches

• [07:37] " Even if you're defending the MAP with epinephrine, you'll get this characteristic rise in lactate, which is concerning, to say the least." — Dr. Elliott Miller

• [15:36] "The fact that in a randomized trial there was no evidence of efficacy difference, no difference in survival, but also no difference in safety profile…that speaks volumes." — Dr. Anthony Carnicelli on the DOREMI trial

• [17:07] "If you choose milrinone and you've made a mistake, you're going to have to live with that mistake for a lot longer than dobutamine." — Dr. Elliott Miller

• [18:51] "Vasoactive medication management is a bit more of an art than it is a science. So experience goes a long way." — Dr. Anthony Carnicelli

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Anthony Carnicelli

• https://www.getcare.muschealth.org/providers/anthony-carnicelli-1376956714

• https://www.linkedin.com/in/anthony-carnicelli-926a0b88

Dr. Elliott Miller

• https://x.com/ElliottMillerMD

• https://www.soccc.org/

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

After more than two decades without a major positive randomized trial in cardiogenic shock, is the evidence finally catching up to the technology? 

In this episode of SoCCC Pre-Rounds, Dr. Simon Parlow sits down with Dr. Jacob Møller, critical care cardiologist and professor at the University Hospital Copenhagen, to unpack microaxial flow pumps and the landmark DanGer Shock trial. Dr. Møller shares how persistence, collaboration, and a bit of luck helped drive a breakthrough in a field that has long needed one.

They explore how these devices work at the bedside, from unloading the left ventricle to reducing myocardial oxygen demand, and what that means in real-world care. The conversation also dives into the challenges of running a high-stakes trial in critically ill patients, along with practical insights on patient selection, complications, lactate trends, and weaning strategies. It’s a sharp look at one of the most important recent advances in cardiogenic shock and where clinicians are still forced to operate without clear evidence.

• Microaxial flow pumps unload the left ventricle: By reducing preload and stroke work, they may lower myocardial oxygen demand and support recovery in shock states.

• The DanGer Shock trial changes the landscape: It’s the first major positive randomized trial in cardiogenic shock in over 20 years, targeting a highly selected STEMI population.

• Patient selection is everything: Only a small fraction of shock patients were eligible, highlighting how precise clinicians must be when applying this therapy.

• Weaning starts earlier than we thought: The most critical window may be the first 12–24 hours, with earlier reassessment for device removal.

• Evidence is still evolving: Outside of trial populations, clinicians must rely on judgment when considering use in non-STEMI or non-ischemic shock.

• [00:00] Introduction to SoCCC Pre-Rounds

• [00:57] Live from ACVC 2026: introducing Dr. Jacob Møller

• [01:15] What are micro axial flow pumps and how do they work?

• [03:52] The origin and evolution of the DanGer Shock trial

• [06:39] Trial results and why they were unexpected

• [07:48] Expanding beyond STEMI: real-world patient selection

• [09:44] Monitoring patients: lactate and hemodynamic trends

• [10:20] Early management challenges and complications

• [11:36] Rethinking weaning strategies

• [12:05] Role of guideline-directed therapy during support

• [12:57] Lessons from running a major clinical trial

• [14:03] Building a research culture in critical care

• [07:51] "After seeing the results of DanGer, we have probably become a little bit more liberal in using the device in other forms of ischemic, like non-STEMI shock." — Dr. Jacob Møller

• [09:46] "We look at trajectories, and we look a lot at lactate. Lactate has to go down in these patients; otherwise, something is wrong." — Dr. Jacob Møller

• [10:33] "You look at the trajectory, so if it goes from 1.5 and starts going down, then you know there's something wrong." — Dr. Jacob Møller

• [13:57] "I'm working in a very small cardiac ICU; we only have seven beds, but we randomized more than 100 patients with out-of-hospital cardiac arrest every year." — Dr. Jacob Møller

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Jacob Møller

• https://www.linkedin.com/in/jacob-eifer-m%C3%B8ller-1b2398300/?locale=en

• https://www.rigshospitalet.dk/

Dr. Simon Parlow

• https://www.ottawaheart.ca/profile/parlow-simon

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

In this episode of SoCCC Pre-Rounds, Dr. Balim Senman and Dr. Andrea Elliott, a cardiologist and critical care physician at the University of Minnesota, dive into the evolving landscape of targeted temperature management (TTM) after cardiac arrest. They explore how temperature control strategies have shifted from early hypothermia trials to modern fever-avoidance methods, with ongoing debates around TTM in critical care. Dr. Elliott discusses landmark studies like Bernard, HACA, TTM, Hyperion, and TTM2, highlighting their impact and limitations.

The conversation delves into the real-world application of temperature targets, considering patient severity, neurologic injury, and the unique challenges posed by ECPR patients. Dr. Elliott also covers the physiological costs of hypothermia, common complications, and practical aspects of managing shivering, devices, and protocols. Whether you're a trainee or an experienced clinician, this episode offers evidence-based insights and practical guidance for optimizing post-arrest care.

• TTM is for comatose survivors: Only patients who remain unresponsive after ROSC benefit; awake patients do not.

• Fever prevention matters most: Trial data on hypothermia vs normothermia are mixed, but fever (>37.7°C) is consistently harmful and must be aggressively avoided.

• One size does not fit all: Patients with longer downtimes or more severe neurologic injury may benefit more from active cooling. Allowing spontaneous hypothermia is reasonable.

• ECPR patients are different: Prolonged CPR and ECMO-based temperature control make them physiologically distinct from patients in major TTM trials.

In This Episode

• [00:00] Introduction

• [02:16] Historical background of TTM

• [03:13] Early human studies and mechanisms

• [04:17] Landmark trials Bernard and HACA

• [06:06] TM1 Hyperion and TM2 trials

• [10:25] Patient selection for TTM

• [11:39] Personalized temperature targeting

• [13:21] Management of hypothermic and normothermic patients

• [15:47] TTM in ECPR and ECMO patients

• [18:09] Drawbacks and risks of hypothermia

• [19:19] Protocols and cooling devices

• [21:59] ECPR-specific cooling techniques

Notable Quotes

• [16:04] "ECPR patients by definition have had refractory arrest, not attaining ROSC. So that 20- 25 minute time is blown out of the water. Our ECPR population has an average of 60 minutes of CPR time, so more than double. So the time for that neurologic injury is extensive." — Dr. Andrea Elliott

• [18:43] "You can actually get into trouble if with some under-resuscitation and some patients, if you get them too cold too quickly, and so you'll have to give extra volume back."— Dr. Andrea Elliott

• [22:37] "The most important thing is to make sure that you avoid fevers in our ECPR patients. We also use cooling towers, so we basically cool the fluid or the blood that is in the tubing outside of the patient so that it goes through a cooling bath."— Dr. Andrea Elliott

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Andrea Elliott

• https://med.umn.edu/bio/andrea-elliott

• https://www.linkedin.com/in/andrea-elliott-5575b4267/

Dr. Balim Senman

• https://www.linkedin.com/in/balim-senman-7561436b/

• https://x.com/BalimSenmanMD

• https://www.soccc.org/

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

In this episode of SoCCC Pre-Rounds, Dr. Simon Parlow is joined by Dr. Hatem Soliman, a leading expert in critical care echocardiography, for a deep dive into the game-changing role of point-of-care ultrasound or POCUS in resuscitation and cardiac intensive care.

Together, they unpack how resuscitative echocardiography can help identify reversible causes of cardiac arrest, like pericardial tamponade or tension pneumothorax, and even guide real-time chest compression placement to improve CPR effectiveness.

Dr. Soliman highlights two must-have views: the apical five-chamber for stroke volume and the short-axis great vessels view to assess RV function and pulmonary pressures.

If you're looking to sharpen your bedside skills and bring more precision to your resuscitation toolkit, this episode is packed with insights you won’t want to miss.

Key Takeaways

• Move beyond the IVC: Hepatic, portal, and renal vein Doppler give a clearer picture of systemic venous congestion than IVC alone.

• Cardiac output needs context: Doppler VTI can mislead unless combined with views like apical five-chamber and timing indices like isovolumetric contraction time.

• Every echo parameter has a pitfall: Never interpret one measure in isolation; always integrate findings with clinical judgment.

• His go-to views in shock? Apical 5 chamber (LVOT VTI) and parasternal short axis of great vessels (PA flow) to assess perfusion and RV afterload.

In This Episode

• [00:00] Introduction to the podcast

• [02:24] Role of echo in cardiac arrest

• [03:43] Training and cautions with echo in CPR

• [06:19] Key skills for new trainees in critical care echo

• [07:33] Physiological assessment in critical care echo

• [09:21] Multi-organ ultrasound and venous congestion

• [11:45] Systemic venous congestion in post-ICU patients

• [12:18] Comprehensive cardiac output assessment

• [15:50] Pitfalls and dangers of critical care POCUS

• [17:18] Favorite echo views in cardiac ICU

Notable Quotes

• [06:33] "Critical care echo is actually complex... you need to further proceed from this basic level to intermediate and then advanced levels in which you will be able to assess physiological changes in the heart." — Dr. Hatem Soliman

• [09:22] "The practice of multi-organ ultrasound and looking beyond the chest cavity for congestion is a very important advancement in point-of-care ultrasound." —Dr. Hatem Soliman

• [17:24] "If I have two views to look at in a very short time... the apical five chamber view to get the LVO TVTI because that immediately gives you a clue about stroke volume and cardiac output." — Dr. Hatem Soliman

Dr. Hatem Soliman

Dr. Hatem Soliman is a cardiac intensivist at Harefield Hospital and senior lecturer at King’s College London. He serves on the executive board of the European Association of Cardiovascular Imaging and the editorial board of JACC: Cardiovascular Imaging. A global educator and author of key POCUS textbooks, Dr. Suleiman is renowned for advancing the use of bedside echocardiography in critical care to improve hemodynamic assessment and patient outcomes.

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Hatem Soliman

• https://www.escardio.org/

• https://www.linkedin.com/in/hatemsoliman/

Dr. Simon Parlow

• https://www.ottawaheart.ca/profile/parlow-simon

Mentioned 

• Doyen A. et al. Portal Doppler Ultrasound in Congestion Assessment (André Denault’s work)

• JACC Imaging, Journal of Cardiovascular Ultrasound

• European & American Resuscitation Guidelines

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

In this episode of SoCCC Pre-Rounds, Dr. Balim Senman sits down with Dr. Courtney Bennett, a critical care cardiologist and echocardiographer at Mayo Clinic Rochester, to unpack the bedside recognition and management of cardiac tamponade. The conversation emphasizes tamponade as a clinical diagnosis, highlighting key physical exam clues such as tachycardia, hypotension, elevated JVP, pulsus paradoxus, and electrical alternans. Dr. Bennett explains the physiology of ventricular interdependence and why the rate of pericardial fluid accumulation matters more than volume alone.

The episode also explores how point-of-care echocardiography supports but does not replace clinical judgment, distinguishing early findings like inflow variation from late signs such as chamber collapse. Management strategies are discussed in real-world terms, including when to urgently drain an effusion, how to stabilize patients with fluids and vasopressors while awaiting intervention, and common pitfalls like inappropriate diuresis. This episode delivers practical, high-yield guidance for clinicians managing undifferentiated shock in the cardiac ICU.

Key Takeaways

• Tamponade is a clinical diagnosis: Pericardial effusion alone does not equal tamponade without hemodynamic compromise

• Tachycardia often comes first: Hypotension and shock may follow as compensation fails

• Small, rapidly accumulating effusions can be fatal, while large chronic effusions may be well tolerated

• Echo supports, not replaces clinical judgment: Chamber collapse suggests late disease; inflow variation may signal early tamponade

• Drain emergently when unstable: Approach and urgency depend on patient trajectory, not imaging alone

In This Episode

• [00:00] Introduction

• [01:11] Definition of cardiac tamponade

• [01:50] Physical exam findings in tamponade

• [03:25] Pulsus paradoxus: definition and mechanism

• [04:57] Etiologies of pericardial effusion

• [05:43] Volume vs. hemodynamic instability

• [06:40] Clinical vs. echo diagnosis of tamponade

• [08:09] Echocardiographic findings in tamponade

• [10:02] Management: tamponade vs. stable effusion

• [12:10] Stabilizing the pre-tamponade patient

• [13:23] Fluid vs. diuretics in tamponade

Notable Quotes

• [01:28] "This is a diagnosis when a patient has pericardial effusion. So excess fluid around the heart that's causing them to have hypotension, low blood pressure, and part of that actually could be what we would describe as Beck's triad." — Dr. Courtney Bennett

• [12:38] "So first and foremost, I would start with IV fluid resuscitation bolus. I don't think there's a well-defined amount that we should use. 500 a liter of fluid. You have to use your clinical assessment because many of our patients may also be peripherally volume overloaded as well. But typically in this scenario, fluid is really the upfront management."— Dr. Courtney Bennett

• [13:48] "Sometimes I work with learners who think that because there's an excess of fluid around the heart, we should be giving diuretics. That's not the case because diuretics will decrease the preload and actually worsen the hypotension."— Dr. Courtney Bennett

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Courtney Bennett

• https://alumniassociation.mayo.edu/colleague-notes/courtney-bennett-d-o/

Dr. Balim Senman

• https://www.linkedin.com/in/balim-senman-7561436b/

• https://x.com/BalimSenmanMD

• https://www.soccc.org/

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

Did you know that pulmonary artery catheters are crucial for patients with unclear shock etiology? In this episode of SoCCC Pre-Rounds, Dr. Elliot Miller sits down with Dr. Aniket Rali, a dual-trained critical care and heart failure cardiologist at Vanderbilt, for a deep dive into the art and science of pulmonary artery catheterization, also known as the Swan-Ganz catheter.

Dr. Rali demystifies the PAC by walking us through the fundamentals of when to use it, who should not get one, and how to interpret and troubleshoot the data it provides. Whether you're a resident inserting your first swan or a fellow refining your hemodynamic assessments, this episode will elevate your bedside practice.

From contraindications and waveform recognition to zeroing, troubleshooting, and avoiding wedge-related complications, Dr. Rali shares high-impact pearls grounded in real-world CICU experience.

Key Takeaways

• Use PACs when shock etiology is unclear; they're diagnostic, not therapeutic

• Avoid PACs in patients with endocarditis, thrombus, or proximal PE

• Know your waveforms; it's your only guide during bedside placement

• Always level and zero the transducer for accurate pressures

• Justify PAC use daily and remove once it’s no longer needed

• Troubleshoot waveform loss by checking positioning, clots, or tubing

• Avoid repeated wedging; use diastolic-to-wedge trends when possible

• Use chest X-ray to confirm safe placement and prevent complications

In This Episode

• [00:00] Introduction

• [01:16] Pulmonary artery catheter basics

• [02:04] Indications for PA catheter use

• [06:57] Special considerations: left bundle and pacemaker leads

• [08:12] Bedside placement preparation and checklist

• [11:33] Presenting PA catheter data on rounds

• [12:03] Ensuring data accuracy and daily safety checks

• [15:17] Sequence for presenting hemodynamic data

• [16:23] Cardiac output measurement methods

• [18:31] Choosing between Fick and thermodilution

• [20:04] Limitations in shunt physiology

• [20:58] Troubleshooting PA catheter issues

Notable Quotes

• [02:17] "At the end of the day, a diagnostic tool is not going to treat your patient. But if it provides you with additional information that helps you reach the right diagnosis, then it becomes a valuable tool." — Dr. Aniket Rali

• [09:07] "I firmly believe that the more you sweat in peace, less you bleed in war. And that holds true of any procedure." — Dr. Aniket Rali

• [10:07] "You really should not be putting in a bedside swan unless you have mastered the waveforms, because the waveforms are your only guidance as to which cardiac chamber you are in." —Dr. Aniket Rali

• [12:31] "I encourage trainees, next time they have a patient with a SWAN Ganz catheter in, to just have them move their arm or move the catheter up by a foot and down by a foot and see how the pressure readings change." — Dr. Aniket Rali

• [27:28] "Long live the swan." — Dr. Aniket Rali

Dr. Aniket Rali

Dr. Aniket Rali is a heart failure and critical care cardiologist at Vanderbilt University. She’s known for her expertise in hemodynamics, real-world application of advanced monitoring, and thoughtful mentorship of trainees learning the art of bedside right heart catheterization.

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Aniket Rali

• https://medicine.vumc.org/department-directory/Aniket-Rali

• https://www.linkedin.com/in/aniket-rali-md-facc-fccp-69ab15228

Dr. Elliot Miller

• https://x.com/ElliottMillerMD

• https://www.soccc.org/

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

How do you diagnose cardiogenic shock quickly and accurately at the bedside? What should your first therapeutic move be? And how do you know if your resuscitation is working?

In this episode of SoCCC Pre-Rounds, Dr. Simon Parlow sits down with Dr. Rebecca Mathew, Director of the Cardiac ICU at the University of Ottawa Heart Institute and co-principal investigator of the CAPITAL Research Group. Together, they break down a clear, real-world approach to diagnosing, stabilizing, and treating cardiogenic shock from the moment the patient arrives.

Drawing from frontline CICU experience and landmark trials such as CAPITAL DOREMI, Dr. Mathew discusses why history and physical exam still drive the diagnosis, how to approach congestion and perfusion, when inotropes actually help, and how to integrate invasive hemodynamics when available. The episode offers practical, bedside-ready guidance for clinicians managing shock in any setting.

Key Takeaways

• Cardiogenic shock is best diagnosed through history, exam, and perfusion assessment, not lactate or invasive data alone.

• SCAI is the most practical framework, but Stage D should be assigned only after a failed therapeutic trial.

• Use inotropes only if hypoperfusion persists after decongestion; dobutamine quickly shows responsiveness.

• Swan-Ganz catheters help when available, but most shock worldwide is managed without invasive hemodynamics.

• [00:00] Introduction 

• [01:06] Importance of initial medical management in cardiogenic shock

• [02:53] Defining cardiogenic shock and SCAI classification

• [05:27] Phenotypes and subtypes of cardiogenic shock

• [07:23] Caveats in SCAI classification

• [07:49] Bedside diagnosis and risk stratification

• [09:53] Physical exam: hyperperfusion and congestion

• [11:54] Initial management approach: decongestion and inotropes

• [14:17] Therapeutic targets and monitoring response

• [15:24] Inotrope selection and individualized therapy

• [16:55] Ongoing research and future directions

• [17:55] Therapeutic targets: clinical and biochemical markers

• [19:47] Mean arterial pressure (MAP) targets

• [03:21] “I think in its most basic sense, I think of cardiogenic shock as a clinical syndrome of clinical and biochemical hyper perfusion that’s due to a primary cardiac disorder.” — Dr. Rebecca 

• [15:48] “People often ask me what inotrope I reach for, and despite having done the DoReMi trial and proving there’s no difference, I am anecdotally a big believer in dobutamine.” - Dr. Rebecca 

• [22:10] “Once you’re in the throes of shock, I think we just need to focus on the tsunami in front of us and manage that.”

• [23:26] “The most exciting thing about cardiac critical care and managing cardiogenic shock is you are basically seeing physiology in real time." — Dr. Rebecca

Dr. Rebecca Mathew

Dr. Rebecca Mathew is a critical care cardiologist and Director of the Cardiac ICU at the University of Ottawa Heart Institute. She leads major cardiogenic shock research programs, including the CAPITAL DOREMI trial published in the New England Journal of Medicine and the ongoing CAPI2 trial focused on early inotrope strategies. Her work spans clinical care, trial leadership, and translational shock physiology.

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Rebecca Mathew

• https://www.ottawaheart.ca/profile/mathew-rebecca

Dr. Simon Parlow

• https://www.ottawaheart.ca/profile/parlow-simon

• https://www.soccc.org/

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.

Should we be using ECMO during cardiac arrest? In this episode of SoCCC Pre-Rounds, Dr. Balim Senman sits down with Dr. Jason Bartos, interventional and critical care cardiologist at the University of Minnesota and one of the nation’s leading voices on extracorporeal cardiopulmonary resuscitation (ECPR). Together, they break down when and why to consider ECMO in cardiac arrest, the patient selection puzzle, and what truly impacts outcomes in the field.

Dr. Bartos shares pearls from the ARREST trial and offers hard-won insights into what it takes to build an ECPR program that saves lives from timing and volume to sedation, TTM, and neuroprognostication. Whether you’re a trainee encountering ECPR for the first time or a team leader building a resuscitation program, this episode delivers essential guidance grounded in real-world experience.

Key Takeaways

• ECPR = ECMO during or shortly after cardiac arrest; best for patients with witnessed arrest and refractory shockable rhythms

• Avoid ECPR in patients with poor baseline function, irreversible comorbidities, or prohibitive vascular anatomy

• Outcomes depend on systems: high-volume centers, early activation, and streamlined protocols improve survival

• Don’t oversedate; sedation is not required for ECMO; prioritize comfort and cannula safety

• Use 37°C TTM with aggressive fever prevention; ECMO allows precise temperature control

• [00:00] Introduction

• [00:45] Episode introduction & guest welcome

• [01:25] What is ECPR?

• [02:14] Rationale and data behind ECPR

• [03:13] Key ECPR trials and outcomes

• [08:56] ECPR patient selection & center volume

• [10:15] Selection criteria details

• [13:06] Absolute and relative contraindications

• [15:11] In-hospital ECPR activation & information gathering

• [16:21] Standardizing in-hospital ECPR response

• [18:22] Timing and team mobilization for ECR

• [19:56] Post-ECMO management: sedation & temperature

• [21:40] Sedation practices on ECMO

• [23:28] Temperature management evolution

• [25:29] Neuroprognostication after ECPR

• [01:34] "ECPR is extracorporeal cardiopulmonary resuscitation. It's the use of ECMO for patients with cardiac arrest." — Dr. Jason Bartos

• [25:40] "The danger to the patients in the ICU post-arrest is us. We really have the task of trying to determine and predict and inform family members of how their loved one is going to do in this worst circumstance of their life." — Dr. Jason Bartos

• [25:29] "Neuroprognostication is near and dear to my heart, partly because I think it's honestly the most important thing we do in the ICU for any post-arrest patient, but particularly for this population." — Dr. Jason Bartos

Dr. Jason Bartos

Dr. Jason Bartos is an interventional and critical care cardiologist at the University of Minnesota. He leads one of the nation’s highest-volume ECPR programs and is a founding member of the Center for Resuscitation Medicine. He is nationally recognized for his leadership in post-arrest care, real-world ECMO implementation, and advancing cardiac arrest science.

Resources and Links

• Become a member of the Community: https://www.soccc.org/subscribe

Dr. Jason Bartos

• https://med.umn.edu/bio/jason-bartos

• https://www.linkedin.com/in/jason-bartos-b6898441

Dr. Balim Senman

• https://www.linkedin.com/in/balim-senman-7561436b/

• https://x.com/BalimSenmanMD

• https://www.soccc.org/

Supported By:

This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.

Disclaimer

This podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.