What do you do when a patient returns from the cath lab hypotensive and unstable? In this episode of SoCCC Pre-Rounds, critical care cardiologists Dr. Ann Gage and Dr. Zach Il'Giovine join host Dr. Elliott Miller to break down the management of post-catheterization hypotensive emergencies. This conversation delves into rapid assessment, differential diagnosis, and life-saving interventions in the acute care setting.
The experts emphasize the importance of taking a moment to gather context before rushing to the bedside. Was it a PCI, EP study, or structural intervention? This pause allows for a more focused differential diagnosis, covering complications such as vascular issues (groin hematoma, retroperitoneal bleed), cardiac tamponade, and acute stent thrombosis.
A standout takeaway: manual pressure is your first-line tool for managing bleeding, and don’t hesitate to call the proceduralist early. They also highlight when to order a CT scan (pro-tip: non-contrast first) and the principles behind massive transfusion protocols.
This episode offers actionable insights for handling hypotensive emergencies with confidence and precision.
Key Takeaways
Build a differential based on the cath details: arterial, venous, pericardial?
Retroperitoneal bleed is high on the list for sudden post-cath hypertension.
First move: Is the patient in extremis? If yes, act. If not, think.
Groin pain or back pain? Start with pressure and basic labs.
For massive bleeds: use balanced transfusions and proper IV access.
In This Episode
[00:00] Introduction
[00:56] Meet the guests: Dr. Ann Gage and Zach Il'Giovine
[02:09] Gathering info before seeing post-cath patient
[03:46] Building the differential diagnosis
[08:13] Physical exam and bedside assessment
[09:57] Hemodynamic assessment and initial workup
[16:00] Massive hemorrhage and transfusion protocols
[17:05] Procedural complications and communication
[19:55] Manual pressure crucial for groin bleeds
Notable Quotes
[04:06] "I was told once by a medicine resident that if you were a good resident, you would have two or three things on your differential, but if you were great, you would appear at the bedside with at least 10 things on your differential." — Dr. Ann
[00:13:55] "Nothing really makes me madder than coming in the morning and seeing that the residents gave contrast to ten people, when if you've got a hemodynamically significant bleed, you do not need contrast." — Dr. Elliott
[00:20:53] "On more than one occasion, manual pressure has saved lives." — Dr. Zach
Dr. Ann Gage
Dr. Ann Gage is a critical care and interventional cardiologist at Centennial Heart in Nashville. She bridges the cath lab and CICU with expertise in both patient care and procedural nuance.
Dr. Zach Il'Giovine
Dr. Zach Il'Giovine is a heart failure and critical care cardiologist at Centennial Heart. He focuses on managing complex ICU patients, procedural complications, and bridging multidisciplinary care.
Resources and Links
Become a member of the Community: https://www.soccc.org/subscribe
Dr. Ann Gage
Dr. Zach IlGiovine
Dr. Elliott Miller
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 sits down with Dr. Jason Katz, advanced heart failure and transplant cardiologist, critical care leader, and president of the Society of Critical Care Cardiology, to dive into the real-world challenges of managing VA ECMO at the bedside.
ECMO can be life-saving, but it’s also one of the most complex tools in the ICU. Dr. Katz breaks down what every trainee needs to know: the difference between VV and VA ECMO, when and how to decide who’s a candidate, and why every cannulation must come with an “exit strategy.” He shares practical insights on navigating the first critical days, staying vigilant for complications like Harlequin syndrome, and when left ventricular venting makes sense.
If you’ve ever felt overwhelmed by the idea of managing a patient on VA ECMO, this episode gives you a clear, practical roadmap so you feel more prepared the next time you see an ECMO consult roll into the CICU.
Key Takeaways
The difference between VV and VA ECMO and why VA supports both the heart and lungs.
Classic indications for VA ECMO: when to consider it for refractory cardiogenic shock or cardiac arrest.
How to decide if your patient has a viable exit strategy, bridge to recovery, bridge to transplant, or bridge to decision.
Harlequin syndrome (differential hypoxemia): What it is, how to detect it, and what to do about it.
Pearls on left ventricular venting and unloading: when to consider a balloon pump, Impella, or atrial septostomy.
In This Episode
[00:00:00] Introduction
[00:00:45] Episode sponsor & guest introduction
[00:01:57] Defining and differentiating VV and VA ECMO
[00:04:47] Indications and patient selection for VA ECMO
[00:06:49] VA ECMO as a bridge and contraindications
[00:10:02] Early management and complications of VA ECMO
[00:14:14] Differential hypoxemia (Harlequin syndrome)
[00:18:18] Left ventricular venting and unloading
Notable Quotes
[05:28] "If there's one thing that is consistent about places that are using VA ECMO is that there is no consistency." — Dr. Jason Katz
[10:18] "You need to think about how you're going to get off the device, again, whether you're hoping for recovery or it's a bridge to an exit strategy like durable VAD or transplantation." — Dr. Jason Katz
[13:48] "Transplantation as an exit strategy. But again, the longer these patients are on these devices, the ECMO is certainly the case. But for every temporary MCS device, the longer they're on these devices, the higher their risk for getting one of these complications." — Dr. Jason Katz
[19:40] "Everything that unloads the heart or unloads the left ventricle is going to vent the left ventricle, but not everything that vents the left heart will necessarily unload or reduce the myocardial oxygen consumption." — Dr. Jason Katz
Dr. Jason Katz
Associate Chief of Cardiology, Bellevue Hospital; Program Director for Advanced Heart Failure and Transplant Fellowship, NYU; President, Society of Critical Care Cardiology. Nationally recognized leader in advanced heart failure, critical care cardiology, and mechanical circulatory support.
Resources and Links
Become a member of the Community: https://www.soccc.org/subscribe
Dr. Jason Katz
Dr. Simon Parlow
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.
Welcome to the first episode of SoCCC Pre-Rounds, your new source for focused, practical conversations in critical care cardiology. In this episode, Dr. Balim Senman sits down with
Dr. Elliott Miller to take you inside the real-world management of ventricular tachycardia (VT) storm, a high-risk emergency that demands both quick action and nuanced decision-making.
They break down what defines a true VT storm, why recognizing polymorphic vs. monomorphic VT changes everything, and how to rapidly assess patient stability when every second counts. You’ll hear how to choose and dose first-line antiarrhythmics, why procainamide is still guideline-preferred but underused, and when lidocaine plays a role, plus what to watch for with toxicity.
The conversation goes deeper than algorithms, highlighting when sedation, intubation, and mechanical support can help break the cycle, and when to escalate to advanced options like stellate ganglion blocks, overdrive pacing, or VT ablation. Real bedside pearls make this episode especially relevant for trainees and anyone wanting to feel more prepared during a cardiac emergency.
Walk away with a clear, actionable framework to tackle VT storm with confidence, and practical reminders to always treat the root cause, not just the arrhythmia.
Key Takeaways:
Understand what VT storm really is and why the type (polymorphic vs. monomorphic) matters.
How to assess if a patient is truly unstable and when immediate defibrillation is needed.
How to choose first-line antiarrhythmics for stable VT, and why procainamide isn’t used as often as the guidelines suggest.
When lidocaine is useful, and how to recognize early signs of lidocaine toxicity.
What a stellate ganglion block is and when it’s a practical option for refractory cases.
In This Episode:
[00:00] Introduction
[00:45] Episode topic introduction: VT storm
[01:19] Definition of VT storm
[02:36] Initial management: stable vs. unstable
[03:00] Unstable VT: immediate actions
[04:46] Stable VT: first-line medications
[07:26] Lidocaine use and toxicity
[10:48] Beta blockers in VT storm
[11:27] Third-line and advanced interventions
[12:05] Stellate ganglion block explained
[15:07] Pacing and anti-tachycardia pacing
[17:54] Episode wrap-up and closing
Notable Quotes
[05:31] "Amiodarone seems to drop from the sky and be in the fountains." — Dr. Elliott Miller
[14:14] "I remember room 4 vividly. So this is HIPAA safe room 4 of my CICU, a patient in his 60s with sarcoid and he would VT on anything but procainamide anytime we tried to switch him off." — Dr. Elliott Miller
[16:51] "Double sequential external defibrillation... I think it’s something you can keep in your back pocket for someone that’s in refractory V fib." — Dr. Elliott Miller
Our Guest
Dr. Elliott Miller
Dr. Elliott Miller is an Assistant Professor of Medicine at Yale School of Medicine and Medical Director of the Cardiac Intensive Care Unit at Yale New Haven Hospital. He specializes in critical care cardiology, with research focused on cardiac arrest, mechanical circulatory support, and CICU systems improvement. A nationally recognized educator, he has received multiple teaching awards and leads efforts to advance care for critically ill cardiovascular patients.
Resource & Links
Become a member of the Community: https://www.soccc.org/subscribe
Dr. Elliott Miller
Dr. Balim Senman
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.
Hosted by members of the Society of Critical Care Cardiology (SoCCC) Pre-Rounds delivers bite-sized, high-yield episodes designed for medical students, residents, fellows, early-career cardiologists, allied health professionals and all enthusiasts of critical care cardiology navigating the complexities of the field.
With only 160 critical care cardiologists in the U.S., mentorship is limited. SoCCC Pre-Rounds fills the gap with expert insights, clinical pearls, and real-world guidance on topics like cardiogenic shock, ECMO, and resuscitation. In short bite sized episodes, top leaders in the field answer key clinical questions—perfect for pre-round prep, night shifts, or sharpening your skills.
Listen in. Level up. Join the SoCCC community.
