VA ECMO update. Jan Bělohlávek, ECMO team Prague Complex cardiovascular center

Transkript

1 VA ECMO update Jan Bělohlávek, ECMO team Prague Complex cardiovascular center General University Hospital, 1 st Medical Faculty Charles University in Prague

2 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

3 Typy indikací Bridge to bridge Bridge to decision Bridge to recovery Bridge to transplant Bridge to destination therapy Bridge to nowhere

4 58% 66%

5 In hospital mortalita Počet případů u a vv- hospitalizační a va-ecmo mortalita vs. věk vs. doba na ECMO

6 ESC + EACTS Guidelines Revasc 2014

7 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 cardiac arrest withour expected fast recovery (immediate PCI, prompt improvement on catecholamines) OHCA/IHCA.in house/out of house septic shock?

8 Chest pain, anterior STEMI, BP of 70/50 mmhg, defibrillated for VF, sweating, cold periphery

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10 Stand-by approach

11 Mortality after 18 monts 81%

12 Hospital volume not associated with mortality. Overall, 34.6% died during VA ECMO, 37.9% died after weaning, 26.5% discharged.

13 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)

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15 Awake ECMO cardiogenic shock

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18 ECMO a elektivní podpora

19 ECMO support during interventions elective cases VERY VERY high risk PCI EP studies (sustained VT with hemodynamic compromise) TAVI

20 Cardiogennic shock/arrest in the cathlab

21 Diagnostics shot in a 3VD patient with immediated hemodynamic collapse

22 PCI on ECMO no intubation! No LV contractions Minimal LV contractions

23 PCI on ECMO no intubation! Stent implantation Post stent implantation

24 Final result PCI Motto: Perfect is enemy of good.

25 Peripheral ECMO V-A Femoro-femoral O 2 pump IVC oxygenator Fem. Art. A profile of patients treated by ECMO. Bělohlávek et al. Interv Acut Cardiol2010; 9(3): 121

26 Peripheral ECMO O 2 subcl./axil. art. V-A Femorosubclavian/axillary pump IVC oxygenator A profile of patients treated by ECMO. Bělohlávek et al. Interv Acut Cardiol2010; 9(3): 121

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28 ECMO and LV interaction (1) ECMO > LV ECMO LV ECMO < LV LV LV LV ECMO Ostadal, Belohlavek. ECMO manual, 2013

29 Hemodynamics during VA ECMO O 2 oxygenator pump IVC LV Fem

30 V-A-V ECMO circuit V-V O 2 IVC LV pump IVC oxygenator Fem. V-A

31 ECMO and LV interaction (2)

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34 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!

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37 7/32 survivors VA ECMO for septic shock good for children and adults with severe septic cardiomyopathy

38 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

39 ECMO in cardiac arrest

40 Extracorporeal CPR continuation in CPR using mechanical circulatory support always VA-ECMO Source: GUH Prague

41 Fagnoul et al., Curr Opin Crit Care 2014 Grunau et al., Prehosp Emerg Care 2016 Cardiac arrest in OHCA 50-70/ annually CPR registries INTCAR registry TTM trial succesfull ROSC patients!!! 30-40% Where are the 60-70% remaining? Dying Refractory cardiac arrest minutes??? Favorable outcome of 2-4%

42 Key consideration? N=1014 6% favorable outcome Refractory cardiac arrest has dismal prognosis

43 Acute myocardial ischemia typical cause of treatable refractory cardiac arrest

44 ECPR studies in OHCA Author Year of publication N Time to ECMO (min) Survival Nagao % Haneya % Kagawa % Nagao % Le Guen % Avalli % Fagnoul % Maekawa % Leick % SAVE-J Sakamoto % CHEER Impl % Choi % Prague OHCA randomized S vs. H (29) 56 (Impl. 14) 28 %

45 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

46 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 monitor brain tissue saturations (NIRS) (mechanical CPR) immediatelly available ABG/ECHO/vascular US primed ECMO device on cathlab/er 24/7

47 Bystander CPR in OHCA in Prague Courtesy of dr. Franěk Prague EMS

48 Initial prehospital care Witnessed cardiac arrest EMS dispatch center Telephone assisted bystander CPR ALS > 5 min CA > min EMS crew dispatched If no ROSC Early SMS alert to cardiac center ECMO team capacity confirmed Call to cardiac center Check for eligibility

49 Hyperinvasive approach to refractory OHCA early alert to cardiac center mechanical chest compressions intra-arrest cooling extracorporeal life support neuromonitoring immediate invasive assesment and treatment SMS LUCAS RhinoChill ECMO NIRS-INVOS CAG/PCI PuAG

50 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

51 Supported by grant of Ministry of Health IGA NT /2012

52 # min

53 # min vessel view under X-ray

54 Cannulation blind ultrasound guided X-ray guided insertion stiff wire no dilatation

55 # min Acute occlusion? YES!

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57 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

58 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

59 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

60 # minutes of mechanical CPR for refractory arrhythmias before ECMO

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62 # 26 Provided informed consent

63 # min Provided informed consent

64 # min

65 # min

66 # min Provided informed consent

67 # min Provided informed consent

68 # min Refractory MODS

69 ECMO u respiračního selhání

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72 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

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76 Lung rest setting Peak insp. pressure cmh 2 O PEEP cmh 2 0 FiO2 30% Frekvence 10/min

77 ECMO PLS/Cardiohelp (Maquet) oxygenátor rotaflow řídící jednotka a pumpa rotaflow konzole Ohřívač/chladič

78 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!

79 V-V ECMO okruh O 2 VJI pumpa ddž oxygenátor Femoro-jugulární Profil pacientů léčených ECMO. Bělohlávek et al. Interv Akut Kardiol 2010; 9(3):

80 V-A-V ECMO okruh V-V O 2 pumpa ddž oxygenátor a. fem V-A

81 dětské ECMO + CRRT

82 On-line biochemické vyšetření

83 RTG Typický obraz plicního postižení u H1N1 chřipky CT

84 H1N letá žena

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