ECMO and VAD implantation
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1 1 Udine ECMO Workshop ECMO and VAD implantation Prof. Tomaso Bottio Division of Cardiac Surgery (Director Prof. Gino gerosa)
2 ECMO Extracorporeal membrane oxygena1on (ECMO) is a rescue therapy to support severe cardiac and/or pulmonary failure.
3 Cardiogenic Shock Most commonly following: Acute myocardial infarc1on Non- ischaemic causes including» Myocardi1s» End- stage cardiomyopathy» Sustained arrhythmias.
4 ECMO: Clinical Strategy Recovery ECMO Bridge to Decision Transplant/ post- transplant Bridge (VAD) Exitus
5 ECMO Advantages in the sehng of cardiogenic shock Easy/rapid implanta1on if peripheral No sterno/cardiotomy Local anesthesia Emergency situa1ons Provides high flow Triage if of doubt about neurological status Mobile Cardiac Assistance Unit Low cost (cheaper than other devices)
6 ECMO ContraindicaIons Not candidates for transplanta1on or durable MCS Chronic organ dysfunc1on (emphysema, cirrhosis, renal failure- dyalisis) Prolonged cardiopulmonary resuscita1on without adequate 1ssue perfusion An1coagulant related contraindica1ons Compliance limita1ons (financial, cogni1ve, psychiatric, and social limita1ons)? Unrecoverable cardiac func1on?
7 never too early! For cardiogenic shock, a support device should be inserted as soon as possible, par1cularly if ( ) fluid resuscita,on and pharmacologic support fail ( ). Early ini1a1on of MCS support can mi1gate the consequences of systemic hypoperfusion, worsening ischemia, and declining cardiac func1on.
8 Multivariable modelling on 3846 patients identified pre-ecmo risk factors for hospital mortality: chronic renal failure, mechanical ventilation, others acute organ failure, cardiac arrest, congenital heart disease, lower pulse pressure, and lower serum bicarbonate Before it s too late!
9 ..and not too long Support < 8 days Survival
10 ECMO Disadvantages in the sehng of cardiogenic shock Time limita1on Pa1ent must remain supine Local Complica1ons (hemorrhages, embolism, acute leg ischemia) Infec1on Stroke (ischemic, hemorrhagic) Pump highly pre- and ayerload dependent Non- pulsa1le flow?
11 ECMO ComplicaIons Mechanical (rela1ng to the ECMO circuit components, cannulas displacement) Medical Bleeding (>30% requiring surgical revision, 2 blood units per day median value) Infec1on (15-20% incidence, median delay 4 days, Gram nega1ve pathogens) Thrombocytopenia Embolism Cerebrovascular and vascular (20%- 30%) Limb ischaemia (15%- 20%) Pulmonary edema Cardiac Thrombosis Coronary or cerebral hypoxia (site of arterial cannula)
12 ECMO and Pulmonary edema Retrograde flow of blood towards the ley ventricle may cause increased increased ley ventricular ayerload, especially if ventricular ejec1on is unable to overcome this pressure gradient. This results in progressive ley ventricular dila1on, pulmonary conges1on, and pulmonary edema. IABP and inotropes Atrial septal puncture PA cannula or catheter Impella Switch from peripheral to central ECMO LV cannula
13 Harlequin syndrome Flow compe11on in the aorta Blue head : deoxygenated blood directed to the upper part of the body Red legs : hyperoxygenated blood in the lower part of the body
14 ECMO and Death The mul1variate logis1c regression analysis showed that the only factors independently associated with death are: Transfusions (Blood Units, Platelets, Plasma) Age CVVH Dura1on of ECMO influence or not mortality?
15 Conclusions ECMO is a Bridge to Life It should be ins1tuted as soon as possible It should be weaned/subs1tuted ideally as soon as possible (within ½- 1 week)
16 ECMO: LVAD ImplantaIon ECMO- Preop cardiogenic shock ECMO- Intraop CP support ECMO- Paracorporeal LVAD LVAD Implanta1on ECMO- Post- op RV Failure
17 ECMO Pre- op and LVAD ImplantaIon Padua experience: Pa1ents: 21 Gender: 18 male/3 female Mortality (30- days- In- Hospital): 7/21 (33%) Bleeding/revision: 10/21 (48%) Infec1on: 10/21 (47,6%) MOF: 1/21 (4,7%) Stroke: 2/21 (9,5%) RV failure and need for RVAD: 5/21 (23,8%) Days on RVAD: 7gg (mean)
18 ECMO Pre- op and LVAD ImplantaIon
19 Padua experience: ECMO Intra- op and LVAD ImplantaIon Pa1ents: 15 Gender: 14 male/1 female Mortality (30- days- In- Hospital): 3/15 (20%) Bleeding/revision: 7/15 (46%) Infec1on: 8/15 (53%) MOF: 0/15 (0%) Stroke: 2/15 (13%) RV failure and need for RVAD: 7/15 (46%) Days on RVAD: 12gg (mean)
20 ECMO Intra- op and LVAD ImplantaIon
21 ECMO Pre- op and Paracorporeal LVAD ImplantaIon Padua experience: Pa1ents: 16 Gender: 9 male/7 female Mortality (30- days- In- Hospital): 6/15 (37,5%) Bleeding/revision: 5/16 (31%) Infec1on: 5/16 (31%) MOF: 1/16 (6%) Stroke: 0/16 (0%) RV failure and need for RVAD: 4/16 (24%) Days on RVAD: 7gg (mean)
22 ECMO Pre- op and Paracorporeal LVAD ImplantaIon
23 ECMO Pre- op and Paracorporeal LVAD ImplantaIon
24 Cardiopulmonary by- pass and LVAD implantaion Padua experience: Pa1ents: 12 Gender: 11 male/1 female Mortality (30- days- In- Hospital): 1/12 (8,3%) Bleeding/revision: 8/12 (67%) Infec1on: 7/12 (58%) MOF: 0/12 (0%) Stroke: 1/12 (8,3%) RV failure and need for RVAD: 1/12 (8,3%) Days on RVAD: 4gg (mean)
25 Off- Pump and LVAD implantaion Padua experience: Pa1ents: 29 Gender: 26 male/3 female Mortality (30- days- In- Hospital): 3/29 (10%) Bleeding/revision: 7/29 (24%) Infec1on: 10/29 (34%) MOF: 0/12 (0%) Stroke: 2/29 (7%) RV failure and need for RVAD: 1/29 (3,4%) Days on RVAD: 6gg (mean)
26 Conclusions Pre- op ECMO Intra- op ECMO ECMO+LVAD CPB OFF- CPB Mortality 33% 20% 37% 8% 10% Bleeding/ revision 48% 46% 31% 67% 24% Infec1on 48% 53% 31% 58% 34% Post- op RVAD 24% 46% 24% 8.3% 3,4%
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