To ECMO Or Not To ECMO Challenges of venous arterial ECMO. Dr Emily Granger St Vincent s Hospital Darlinghurst NSW
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1 To ECMO Or Not To ECMO Challenges of venous arterial ECMO Dr Emily Granger St Vincent s Hospital Darlinghurst NSW
2 The Start: 1972 St Vincent s Hospital
3 The Turning Point ECMO program restarted in patients in respiratory failure Successfully supported and weaned from VV ecmo Further experience during H1N1 influenza pandemic Centrifugal Pump Percutaneous Femoral Cannulation Polymethylpentene Oxygenator Heparin Coated Lines
4 Increased activity
5 Veno-Arterial ECMO (VA ECMO) Maquet Heater Unit Jostra Quadrox D Bioline Coated Bioline Coated Arterial Femoral Cannula Tubing is bioline coated Jostra Rotaflow Pump Drive Tubing is bioline coated Bioline coated Venous Femoral Cannula Jostra Rotaflow Console
6 Challenges of va ECMO 1. Post cardiotomy 2. CPR ECMO 3. The non-ejecting heart Day/Month/Year Footnote to go here Page 6
7 Published post cardiotomy results survival 16-48%
8 Post cardiotomy va ECMO Results patients requiring post cardiotomy ECMO support. 44 post cardiac transplant 39 after general cardiac surgery (cabg, valve etc).
9 Post heart transplant (44) Va ecmo Primary allograft failure Average age 47 Only 3 central cannulations Average duration 4.6 days (2-13) 6 deaths within 30 days (13.6%): MOF, sepsis 16 deaths overall: rejection, sepsis, malignancy Average Time to death 478 days (0-1786) Day/Month/Year Footnote to go here Page 9
10 Post general CTS (39) Average age 51 (20-79) 3 vv, 1 vpa, 35 va 5 central Average support 6.1 days (1-23 days) 14 within 30 days cardiac failure/cva 36% Average time to death 227 days (1-1733) 21 deaths overall Day/Month/Year Footnote to go here Page 10
11 ELSO Comparison: Complications (Adult) Type of complication SVH VA (% reported) International VA Haemorrhagic: GI haemorrhage Haemorrhagic: Cannulation site bleeding Haemorrhagic: Surgical site bleeding 3 (2.3) 254 (4.2) 15 (11.6) 1150 (19.0) 48 (37.2) 1298 (21.5) Renal replacement total 54 (41.9) 2364 (39.1) CVS: Inotropes on ECLS 107 (82.9) 3442 (57.0) CVS: CPR required 1 (0.8) 267 (4.4) CVS: Myocardial stun by ECHO 14 (10.9) 341 (5.6) CVS: cardiac arrhythmia 14 (10.9) 1027 (17.0) CVS: Hypertension requiring vasodilators 1 (0.8) 256 (4.2)
12 Summary ~12% cannulation site bleeding Surgical site bleeding va ECMO 37% 40% require haemodialysis during ECMO >75% need inotropes on ECMO 3% CVA rate mean post-operative survival of 26 ± 4.5months 36% 30-day mortality No one dies without ECMO?
13 Date Author Journal Country Technique Numbers Comments March 2016 Hong ASAIO Journal January Eastaugh Paediatric 2015 critical care medicine May 2015 Lin Journal American College of Cardiology South Korea Transaortic catheter venting 7?UK Percutaneous LA venting 44 Paediatric South Korea Percutaneous transseptal LA venting 6 August 2014 Sandrio Cardiology in the young November 2014 January- February 2011 Germany Right superior pulmonary vein LV vent Foley Circulation?US Antero-lateral thoracotomy LV apical vent Avali ASAIO Italy Percutaneous pulmonary artery venting August 2013 Attisani European Heart Journal May 2012 Sandrio Cardiology in the young December 2011 Narain Critical care medicine Italy Germany US Minimally invasive transapical left ventricular vent Right superior pulmonary vein LV vent Percutaneous transaortic valve Impella 8 Paediatric. Sternotomy 8 1 Emergent for LV thrombus 16 Adult and paediatric 5 Paediatric. Sternotomy 1 Impella device Day/Month/Year Footnote to go here Page 13
14 The non-ejecting heart on va ECMO 2011 july va ECMO patients 4 primary graft failure post cardiac transplant 2 acute myocarditis 1 VAD thrombosis 4 post cardiotomy shock 11 patients (5.2%) required venting. 10 vents were inserted surgically, 1 percutaneously Mean duration of venting was 76.2±17.2 hours. survival was 6 of 11 patients (55%). Day/Month/Year Footnote to go here Page 14
15 Summary Challenging group High mortality High CVA rate Non ejecting, distended LV does not recover Percutaneous trans septal puncture for non cardiotomy cases Right superior pulmonary vein LV vent for sternotomies?impella device Day/Month/Year Footnote to go here Page 15
16 ECMO CPR: who, when, how? Out of Hospital Cardiac Arrest (OHCA) survival ranging from 2-11% In-hospital arrest survival rates 15-22% Severe neurological deficits occur in up to 30-60% of OHCA and 10-20% of IHCA survivors RPA, St Vincent s Hospital Sydney 37 patients Day/Month/Year Footnote to go here Page 16
17 EXTRACORPOREAL CARDIOPULMONARY RESUSCITATION FOR REFRACTORY CARDIAC ARREST: A MULTICENTRE AUSTRALIAN EXPERIENCE 25 (68%) were for in-hospital cardiac arrests Median age was (73%) were male Median time from arrest to initiation of ECMO flow was 45 minutes median time on ECMO was 3 days Angiography was performed in 54% of patients 27% required subsequent coronary intervention (stenting or balloon angioplasty 24%) Day/Month/Year Footnote to go here Page 17
18 Complications Major bleeding events occurred in 14 (38%) 28 (76%) patients required red blood cell transfusion Seven (19%) patients experienced ischaemic limb complications 1 amputation Renal replacement therapy was required in 12 (32%) patients. Day/Month/Year Footnote to go here Page 18
19 EXTRACORPOREAL CARDIOPULMONARY RESUSCITATION FOR REFRACTORY CARDIAC ARREST: A MULTICENTRE AUSTRALIAN EXPERIENCE 13 patients (35%) survived to hospital discharge (IHCA 33% vs. OHCA 37%) All survivors were discharged with favourable neurological outcome Pre-ECMO lactate level was predictive of mortality Day/Month/Year Footnote to go here Page 19
20 CPR ECMO Results are encouraging Early insertion Peripheral cannulation Peripheral limb perfusion must be closely monitored - Backflow cannula for distal perfusion if required Keep the heart ejecting on va ECMO 2 CHEER trial Prospective Observational study of mechanical cardiopulmonary resuscitation (CPR), hypothermia, extracorporeal membrane oxygenation (ECMO) and early reperfusion for refractory cardiac arrest in Sydney Day/Month/Year Footnote to go here Page 20
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