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1 : Definition End-organ hypoperfusion secondary to cardiac failure Venoarterial ECMO: Patient Selection Michael A. Samara, MD FACC Advanced Heart Failure, Cardiac Transplant & Mechanical Circulatory Support Minneapolis Heart Institute at Abbott Northwestern Hospital No Financial Disclosures Will discuss off-label use of medical devices Hemodynamics Persistent hypotension Systolic BP < mmhg or MAP 30 mmhg below baseline Cardiac Index < 1.8 L/min/m 2 without support < 2.0 L/min/m 2 with support Elevated Filling Pressures LVEDP > 18 mmhg RVEDP > mmhg Clinical Signs/Symptoms Poor urine output Altered mentation Cool periphery Abdominal pain/n/v Lactic acidosis and HCO 3 Pulmonary congestion : A Spectrum of Disease Cardiac Power Output is the best Hemodynamic Predictor of Survival % Mortality Pre-shock Mild Shock Severe Shock Profound Refractory Shock Refractory (RCS) is almost uniformly fatal without provision of mechanical circulatory support 3% 7.5% 21% 42% 80% No inotropes Low-dose Moderate-dose High-dose (1) High-dose (2) High-dose (3) Inotropic Support HIGH DOSE: Epinephrine > 10 mcg/min; Dopamine > 10 mcg/kg/min; Dobutamine > 10 mcg/kg/min; Milrinone > 0.50 mcg/kg/min ADEQUATE ORGAN PERFUSION FLOW PRESSURE Cardiac Cardiac Output x MAP Power = Output 451 Samuels LE. J Card Surg 1999;14: J Am Coll Cardiol 2004;44:340 8 : Short-term Survival with IABP Tailored Approach to Temporary MCS in Refractory Failure 50 CARDIO- PULMONARY Pulmonary + RV RA-LA ECMO 40 Pulmonary + LV/BiV VA ECMO Mortality (%) ?? OLOGY OF FRACTORY FAILURE CARDIAC RV Failure LV Failure prvad plvad Tandem PVAD Impella Tandem PVAD BiV Failure prvad/plvad Tandem PVAD N Engl J Med 2012; 367: Time after Randomization (Days) PULMONARY VV ECMO J Am Coll Cardiol 1998; 31: AllinaHealthSystem 1

2 Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO) Centrifugal pump + Oxygenator po 2 65 po pco 2 43 Rapid Initiation pco 2 30 Mixing (< 20 min) Cloud Robust Circulatory ECMO po 2 42 Support pco 2 65 (7-8 lpm) Blood Bad Blood Cardiopulmonary Support Aortic Arch VA ECMO Patient Selection 1. Refractory Cardiogenic Shock 2/2 AMI 2. Refractory Cardiogenic Shock 2/2 Myocarditis 3. Extracorporeal CPR 4. Postcardiotomy Shock 5. Cardiomyopathy of Sepsis/Drugs/Toxins 6. Transplant Primary Graft Failure 7. Massive Pulmonary Embolism Profound Shock SBP < 75 mmhg + IABP + Dopamine > 60 mcg/kg/min Crit Care Med 2010; 38: Crit Care Med 2010; 38: p = Profound Shock SBP < 75 mmhg + IABP + Dopamine > 60 mcg/kg/min ECMO vs IABP + ECMO ECMO vs Impella/Tandem Heart -ECMO Crit Care Med 2010; 38: Intensive Care Med (2016) 42: AllinaHealthSystem 2

3 VA ECMO for Fulminant Myocarditis with Refractory ANCHOR Assessment of ECMO in acute myocardial infarction with Non-reversible, Cardiogenic shock to Halt Organ failure & Reduce mortality. This study is a prospective, open-label, multicenter, randomized, controlled trial including patients with ongoing myocardial ischemia complicated by cardiogenic shock with the intention to undergo early revascularization. The study goal is to determine if early VA-ECMO insertion in conjunction with optimal medical treatment is superior to optimal medical treatment alone after early revascularization. Crit Care Med 2011; 38: ) VA ECMO for Fulminant Myocarditis with Refractory Outcomes of Temporary MCS for Refractory 90 patients with RCS over 5 years at Columbia Presbyterian 49% myocardial infarctions; 27% acute decompensated heart failure Median duration of support 8 days Overall survival to hospital discharge = 49% Crit Care Med 2011; 38: ) J Heart Lung Transplant 2013;32: Outcomes of Temporary MCS for Refractory Algorithmic Approach to Patients with Refractory Refractory (n=90) Bridge to Decision Device Short-term VAD (n=44) preferred choice VA ECMO (n=46) for unknown neurologic status, severe hemodynamic instability, or severe coagulopathy Survival (days) Destinations Exchange to implantable VAD (n=23) Explant for myocardial recovery (n=16) Heart transplantation (n=9) Death (n=42) 26% of patients went on to durable VAD One-year survival of 77% 18% of patients had device explant for myocardial recovery and had a one year survival of 100% 11% underwent heart transplantation and had a one year survival of 75% J Heart Lung Transplant 2013;32: Thiele et al, EAPCI 2012; Kapitel 23 AllinaHealthSystem 3

4 ECPR: VA ECMO facilitated CPR ECPR vs. Conventional CPR (CCPR): In-Hospital Cardiac Arrest National Taiwan University 3-year prospective observational study 975 patients with in-hospital cardiac arrest with > 10 min CPR 113 with conventional CPR 59 with extracorporeal CPR Chen et al, Lancet 2008; 16;372(9638): Chen et al, Lancet 2008; 16;372(9638): Meta-analysis: ECPR vs. CCPR Cardiac Arrest Survival Meta-analysis: ECPR vs. CCPR Favorable Neurologic Outcome Intensive Care Med (2016) 42: Intensive Care Med (2016) 42: VA ECMO for Refractory Postcardiotomy VA ECMO for Refractory Postcardiotomy In hospital mortality comparable to cardiac arrest AllinaHealthSystem 4

5 Postcardiotomy Shock: Prompt Provision of Mechanical Support is Critical VA ECMO: Primary Graft Failure s/p Heart Transplantation VA ECMO use at Texas Heart: In OR after unsuccessful weaning from CPB (immediate) Following transfer to ICU (delayed) % Survival LVAD implanted immediately LVAD implant delayed Timing of VA ECMO Implantation J Card Surg 2011;26: European Journal of Cardio-thoracic Surgery 40 (2011) VA ECMO: Primary Graft Failure s/p Heart Transplantation VA ECMO: Primary Graft Failure s/p Heart Transplantation Conditional survival for patients with PGF surviving first year = those without PGF European Journal of Cardio-thoracic Surgery 40 (2011) European Journal of Cardio-thoracic Surgery 40 (2011) VA ECMO for Refractory Cardiovascular Dysfunction in Septic Shock VA ECMO for Refractory Cardiovascular Dysfunction in Septic Shock Crit Care Med 2013; 41: Crit Care Med 2013; 41: AllinaHealthSystem 5

6 VA ECMO Patient Selection Conditions Commonly Associated with Favorable Clinical Outcomes 1. Acute myocardial infarction Without MSOF or sepsis With early/percutaneous revascularization Conditions with Unfavorable or Variable Clinical Outcomes 1. Acute myocardial infarction With MSOF or sepsis With late/surgical revascularizatoin Intra-aortic Balloon Pump Patient selection is critical. The goal is to improve meaningful survival, not to prolong the dying process. 2. Acute fulminant myocarditis 3. Initial presentation of cardiomyopathy 2. Sepsis with myocardial depression 3. Post cardiotomy shock 4. Transplant primary graft failure 5. Drug overdose 6. Pulmonary embolism 7. Pre/post lung transplant with severe pulmonary arterial hypertension Pagani et al. Ann Thorac Surg 2000; 70: Factors Associated with Increased Mortality: 1. Chronic renal failure 2. Longer duration of mechanical ventilation prior to ECMO 3. Pre-ECMO cardiac arrest 4. Lower ph/hco3-5. Congenital heart disease 6. Lower pulse pressure ` Factors Associated with Increased Survival: 1. Younger age 2. Lower weight 3. Acute myocarditis 4. Heart transplant (primary graft failure) 5. Refractory VT/VF Eur Heart J Sep 1;36(33): Eur Heart J Sep 1;36(33): Relative Contraindications to VA ECMO Chronic Conditions Associated with Poor VA ECMO Survival 1. Age > 70 years 2. Active malignancy 3. Severe brain injury 4. Immunosuppression 5. Advanced HIV 6. Severe symptomatic chronic organ failure 1. Cirrhosis 2. End-stage renal disease 3. Pulmonary arterial hypertension Acute Conditions Associated with Poor VA ECMO Survival 1. Advanced shock 1. Lactate > 15 or ph < Anuria > 4 hours (prior to ECMO) AST/ALT 3. > 2000, INR > Advanced microcirculatory failure Shock Primarily 2. 2/2 mitral or aortic regurgitaiton 3. Aortic dissection Michael Samara, MD FACC michael.samara@allina.com Thank You! The ANW CICU/CTICU Nurses SpecialtyCare Perfusionists Our Patients & Their Families AllinaHealthSystem 6

4/22/2016 Updated. AllinaHealthSystem. Cardiogenic Shock: Definition. No Disclosures. Cardiogenic Shock: Declining (But Still High) Case Fatality Rate

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