VA ECMO update Jan Bělohlávek, ECMO team Prague Complex cardiovascular center General University Hospital, 1 st 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
58% 66%
In hospital mortalita Počet případů u a vv- hospitalizační a va-ecmo mortalita vs. věk vs. doba na ECMO
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 cardiac arrest withour expected fast recovery (immediate PCI, prompt improvement on catecholamines) 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%
Hospital volume not associated with mortality. Overall, 34.6% died during VA ECMO, 37.9% died after weaning, 26.5% discharged.
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
ECMO support during interventions elective cases VERY VERY high risk PCI EP studies (sustained VT with hemodynamic compromise) TAVI
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.
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
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
ECMO and LV interaction (1) ECMO > LV ECMO LV ECMO < LV LV LV LV ECMO Ostadal, Belohlavek. ECMO manual, 2013
Hemodynamics during VA ECMO O 2 oxygenator pump IVC LV Fem
V-A-V ECMO circuit V-V O 2 IVC LV pump IVC oxygenator Fem. V-A
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
Fagnoul et al., Curr Opin Crit Care 2014 Grunau et al., Prehosp Emerg Care 2016 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? Dying Refractory cardiac arrest 10 16.30 minutes??? Favorable outcome of 2-4%
Key consideration? N=1014 6% favorable outcome 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 monitor brain tissue saturations (NIRS) (mechanical CPR) 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 EMS dispatch center Telephone assisted bystander CPR ALS > 5 min CA > 15-20 min EMS crew dispatched If no ROSC Early SMS alert to cardiac center ECMO team capacity confirmed Call to cardiac center Check for eligibility
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
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
# 26 73 minutes of mechanical CPR for refractory arrhythmias before ECMO
# 26
# 26 Provided informed consent
# 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 cmh 2 O PEEP 10-15 cmh 2 0 FiO2 30% Frekvence 10/min
ECMO PLS/Cardiohelp (Maquet) oxygenátor rotaflow řídící jednotka a pumpa rotaflow konzole 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!
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): 121 128
V-A-V ECMO okruh V-V O 2 pumpa ddž oxygenátor a. fem V-A
dětské ECMO + CRRT
On-line biochemické vyšetření
RTG Typický obraz plicního postižení u H1N1 chřipky CT
H1N1 2011 24-letá žena
H1N1 u 6 měsíční holčičky 14. den na V-V ECMO