VA ECMO update

Jan Bělohlávek, ECMO team Prague

Complex cardiovascular center

General University Hospital, 1st Medical Faculty

Charles University in Prague

Indikace ECMO

• Těžké kardiální a/nebo respirační selhání

• Rezistentní kardiogenní šok

• Srdeční zástava, akcidentální hypotermie

• ARDS, selhání štěpu po Tx, reperfuzní edém po

PEA, H1N1

• Respirační selhání u novorozenců

• Elektivní podpora: PCI, RFA, kardiochirurgie

Schwarz B, Crit Care Med 2003; Hemmila,, Annals of Surgery 2004; Bakhtiary F, J Thorac Cardiovasc Surg 2008; Ravi R, Ann

Thorac Surg 2009;Arlt M, Resuscitation 2008; Gregoric ID, J Heart Lung Transplant. 2008; Marasco SF, Heart Lung Circ 2008;

Fiser S, Ann Thorac Surg 2001; Marasco , J Heart Lung Transplant 2005; Asaumi Y, Eur Heart J 2005; Scaife ER, J Pediatr

Surg 2007; J Thorac Cardiovasc Surg 2007; Resuscitation 2009; Pereszlenyi A, Eur J Cardiothorac Surg 2002; Aigner, Eur J

Cardiothorac Surg 2007; Hsu HH, J Heart Lung Transplant 2008; Berman M, Ann Thoac Surg 2008; Peek GJ, CESAR trial.

Lancet. 2009; Horton S, Perfusion 2004; Camboni D, Interact Cardiovasc Thorac Surg 2009; Booth KL, JACC 2002

Typy indikací

• Bridge to bridge

• Bridge to decision

• Bridge to recovery

• Bridge to transplant

• Bridge to destination therapy

• Bridge to „nowhere“

66% 58%

Počet případů a hospitalizační mortalita vs. doba na

ECMO

In hospital mortalita

u vv- a va-ECMO vs. věk

ESC + EACTS

Guidelines Revasc 2014

VA ECMO update – setting

• cardiogenic shock • stand-by

– fast recovery possible or expected

– dry-primed ECLS + perfusionist with coffee in the cathlab

– femoral artery and vein for eventual ecmo cannulated with standard

sheats

• implantation

– rapidly crashing…

– withour expected fast recovery (immediate PCI, prompt

improvement on catecholamines)

• cardiac arrest • OHCA/IHCA….in house/out of house

• septic shock?

Chest pain, anterior STEMI, BP of 70/50 mmHg,

defibrillated for VF, sweating, cold periphery

Stand-by approach

Mortality after

18 monts

81%

Overall, 34.6% died

during VA ECMO,

37.9% died after

weaning,

26.5% discharged.

Hospital volume not associated with

mortality.

4 kohortové studie – 235 pacientů s CS po AMI O 33% vyšší 30-denní přežití vs. IABP, ale žádný rozdíl pro TandemHeart/Impella 10 studií se srdeční zástavou – 3098 pacientů O 13% vyšší 30-denní přežití (NNT 7.7) a o 14% vyšší výskyt norm. neurol. výsledku (NNT 7.1)

„Awake ECMO“ cardiogenic shock

ECMO a elektivní podpora

VERY VERY high risk PCI

EP studies (sustained VT with hemodynamic compromise)

TAVI

ECMO support

during interventions – elective cases

Cardiogennic shock/arrest

in the cathlab

Diagnostics shot in a 3VD patient with

immediated hemodynamic collapse

PCI on ECMO – no intubation!

No LV contractions

Minimal LV contractions

PCI on ECMO – no intubation!

Stent implantation

Post stent implantation

Final result PCI

Motto: „Perfect is enemy of good….“

O2

pump

oxygenator

V-A

Femoro-femoral

Fem. Art.

IVC

Peripheral ECMO

A profile of patients treated by ECMO. Bělohlávek et al. Interv Acut Cardiol2010; 9(3): 121–

128

O2

pump

oxygenator

subcl./axil.

art.

IVC

V-A

Femoro-

subclavian/axillary

A profile of patients treated by ECMO. Bělohlávek et al. Interv Acut Cardiol2010; 9(3): 121–

128

Peripheral ECMO

ECMO and LV interaction (1)

ECMO > LV ECMO ≈ LV ECMO < LV

Ostadal, Belohlavek. ECMO manual, 2013

ECMO

LV

LV LV

O2

pump

oxygenator Fem

IVC

LV

Hemodynamics during VA ECMO

V-A-V ECMO circuit

O2

pump

oxygenator Fem.

IVC

V-V

V-A

IVC LV

ECMO and LV interaction (2)

• increasing EBF in cardiogenic shock during

peripheral VA ECMO impairs LV performance

in a flow dependent manner

• optimal VA ECMO flow should be as low as

possible to sustain adequate tissue perfusion

ECMO is circulatory

support, not LV support!

7/32 survivors

VA ECMO for septic shock

– good for children

and adults with severe septic

cardiomyopathy

VA ECMO

• standard of care

• as a circulatory support for

cardiogenic and septic shock

• for refractory cardic arrest - ECPR

• current evidence controversial

• needs randomized studies

ECMO in cardiac arrest

Extracorporeal CPR

• continuation in CPR using mechanical

circulatory support

• always VA-ECMO

Source: GUH Prague

Cardiac arrest in OHCA 50-70/100.000 annually

• CPR registries

• INTCAR registry

• TTM trial

succesfull ROSC patients !!!

30-40%

Where are the 60-70% remaining?

Refractory cardiac arrest 10…16….30 minutes ???

Favorable outcome of ≈ 2-4%

Fagnoul et al., Curr Opin Crit Care 2014

Grunau et al., Prehosp Emerg Care 2016

Dying…

N=1014

6% favorable outcome

Key consideration?

Refractory cardiac arrest

has dismal prognosis…

Acute myocardial ischemia

typical cause of treatable refractory cardiac arrest

ECPR studies in OHCA

Author Year of

publication

N Time to

ECMO (min)

Survival

Nagao 2000 36 67 25 %

Haneya 2012 26 70 15 %

Kagawa 2012 42 59 24 %

Nagao 2010 171 66 12 %

Le Guen 2011 51 120 4%

Avalli 2012 18 77 6 %

Fagnoul 2013 53 66 21 %

Maekawa 2013 53 49 32 %

Leick 2013 28 44 39 %

SAVE-J Sakamoto 2014 260 - 12 %

CHEER 2014 11 Impl. 20 27%

Choi 2016 320 54 9%

Prague OHCA randomized S vs. H 2016 65 (29) 56 (Impl. 14) 28 %

An „optimal“ patient for ECPR

• refractory cardiac arrest (>16 min)

• no comorbidities

• witnessed cardiac arrest

– EMS

– public place

• assumption of correctable cause (ACS)

• shockable rhythm (VF/VT)

• intermittent ROSC

Prerequsites for ECPR

• resuscitation team

• 24/7 (15 min) available ECMO team

(intensivist/cardiologist/perfusionist/surgeon?)

• close cooperation with EMS in cases of OHCA

• early alert system for ECMO/cathlab teams

• be able to admitt and cath under ongoing CPR (mechanical CPR)

• monitor brain tissue saturations (NIRS)

• immediatelly available ABG/ECHO/vascular US

• primed ECMO device on cathlab/ER 24/7

Bystander CPR in OHCA in Prague 2003-2015

Courtesy of dr. Franěk – Prague EMS

Initial prehospital care

Witnessed cardiac arrest

Telephone assisted bystander CPR

EMS crew

dispatched

EMS dispatch center

ALS > 5 min

CA > 15-20 min

Call to cardiac center

Check for eligibility

If no ROSC

Early SMS alert

to cardiac center

ECMO team

capacity confirmed

„Hyperinvasive“ approach to refractory OHCA

• early alert to cardiac center

• mechanical chest compressions LUCAS

• intra-arrest cooling RhinoChill

• extracorporeal life support ECMO

• neuromonitoring NIRS-INVOS

• immediate invasive assesment CAG/PCI

and treatment

PuAG

SMS

Guidelines ERC 2015

Extracorporeal Cardiopulmonary Resuscitation (eCPR)

Extracorporeal CPR (eCPR) should be considered as a

rescue therapy for those patients in whom initial ALS

measures are unsuccessful and, or to facilitate specific

interventions (e.g. coronary angiography and percutaneous

coronary intervention (PCI) or pulmonary thrombectomy for

massive pulmonary embolism).

Hyperinvasive approach uses ECPR

as a one of several stepwise interventions

within changed

prehospital and early hospital logistics

Supported by grant of Ministry of Health IGA NT13225-4/2012

# 46 45 min

# 46 45 min

vessel view under X-ray

Cannulation

blind

ultrasound guided

X-ray guided insertion

stiff wire

no dilatation

# 46 45 min

Acute occlusion? YES !

ECPR - conclusion

• rescue method for refractory cardiac arrest • refractory VF/VT

• witnessed cardiac arrest

• intermittent ROSC

• recommended in ERC 2015 guidelines

• crucial to continue in randomized studies

• organ donorship as a byproduct

Clinical consequencies

• Not ECLS alone,

but „comprehensive approach“ including ECLS may

have an impact on logistics for OHCA patients

• patients who need ECLS for refractory OHCA

have often severe unresolvable cause

• we have technology, now we have to find right

patients and optimize logistics.

• future? • EPR – emergency preservation and resuscitation

» Drabek et al., 2014

Is it ethical to put a patient on a device

to extend CPR?

• uncertain risk-benefit profile

• inability to obtain informed consent

• high cost

• Grave prognosis

• Potential Harms

• Failed recovery….“bridge to nowhere“

• prolonged ICU stay

• Judge: averting death with ECPR may foreclose

the chance for „good death“

Riggs, Resuscitation 2015

73 minutes of mechanical CPR for refractory arrhythmias before ECMO

# 26

# 26

Provided informed consent

# 26

# 48 75 min

Provided informed consent

# 52 51 min

# 52 51 min

# 52 51 min

Provided informed consent

# 52 51 min

Provided informed consent

# 55 78 min

Refractory MODS

ECMO u respiračního selhání

ARDS (acute respiratory distress syndrome)

• typ akutního, difuzního, zánětlivého poškození

plic, které vede ke zvýšení plicní vaskulární

permeability, zvýšení váhy plic a ztrátě vzdušnosti

• Morfologické známky

– difuzní alveolární poškození

• edém, zánět, hyalinní blanky nebo krvácení

• Klinické známky

– hypoxémie a bilaterální plicní infiltráty

– větší mrtvý prostor

– snížená compliance plic

„Lung rest setting“

• Peak insp. pressure 20-25 cmH2O

• PEEP 10-15 cmH20

• FiO2 30%

• Frekvence 10/min

oxygenátor

rotaflow řídící

jednotka a pumpa

rotaflow konzole

ECMO – PLS/Cardiohelp (Maquet)

Ohřívač/chladič

Typy ECMO

V-A

• oběhová (BiV) podpora

• respirační podpora

• totální nebo parciální

• smíchávání toků v aortě

• žilní a arteriální kanylace

• pokles preloadu

• mírný vzestup afterloadu

• zvýšení „wall stresu“ LK

• přetížení LK

– plicní hypoperfuze

– riziko trombózy LS/LK

V-V

• podpora respiračních

funkcí

• podmínkou je uspokojivá

funkce LK i PK

• jen žilní kanylace

• 2x single/double lumen

• riziko recirkulace

• minimální efekt na CVP,

plnění PK, LK a celkovou

hemodynamiku

• systémová hemodynamika

je na VV-ECMO nezávislá!

O2

pumpa

oxygenátor

VJI

ddž

Femoro-jugulární

V-V ECMO okruh

Profil pacientů léčených ECMO. Bělohlávek et al. Interv Akut Kardiol 2010; 9(3): 121–128

V-A-V ECMO okruh

O2

pumpa

oxygenátor a. fem

ddž

V-V

V-A

dětské ECMO + CRRT

On-line biochemické vyšetření

Typický obraz

plicního

postižení

u H1N1 chřipky

RTG

CT

H1N1 2011 – 24-letá žena

H1N1 u 6 měsíční holčičky 14. den na V-V ECMO