Extra Corporeal Life Support for Acute Heart failure

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Extra Corporeal Life Support for Acute Heart failure Benjamin Medalion, MD Director Heart and Lung Transplantation Department of Cardiothoracic Surgery Rabin Medical Center, Beilinson Campus, Israel

Mechanical Assistance availabe Short term (Centrifugal/Axial pumps) LVAD RVAD BiVAD ECMO

Levitronix The Levitronix CentriMag VAS is designed to provide temporary support for patients suffering potentially reversible cardiogenic shock. FDA approved for up to 30 days of use.

Cannulation

J Thorac Cardiovasc Surg 141:932-9 ; 2011

Impella The Impella 2.5 is inserted percutaneously The Impella 5 is inserted surgically Both provide temporary support for patients suffering potentially reversible cardiogenic shock. It is intended to be used up to 7 days

At 30 days - alive 6/23 (26%) Impella 2.5 6/12 (50%) Impella 5

At 30 days - alive 11/29 (38%) Impella 5 13/32 (41%) ECLS

Tandem Heart The Tandem Heart is inserted percutaneously transeptal. It provides temporary support for patients suffering potentially reversible cardiogenic shock. It is intended to be used up to 7 days

IABP = 20 Tandem Heart = 21

ECLS Extra Corporeal Life Support A bedside mobile cardiopulmonary bypass system that can replace the Heart and Lung function. Pump Oxygenator Heater/Cooler

Purpose of Treatment Providing organ perfusion during Heart and/or Lung failure Fast less invasisve and reliable Cannulae insertion Awake ECMO whenever possible

VA ECMO

Distal Perfusion

Physiology Blood is actively drained by a pump from right atrium into an Oxygenator where gas exchange is taking place Blood is than warmed and returned into the arterial circulation

VA ECMO Hemodynamic and Respiratory support Non pulsatile flow Decrease in preload (Rt>Lt) Increase in LV afterload LV ejection is mandatory to prevent: LV distension LV clotting Pulmonary congestion IABP, surgical drainage, atrial septostomy

Complications Hemolysis 5% Infection 40% Leg or Arm ischemia 25% Organ dysfunction 33% Mechanical 4% Bleeding 48% DIC Heparin Stroke 12% Hemmorhagic Embolic

Indications Reversible insult or as a bridge Post cardiotomy Post MI Myocarditis Post Heart TX or LVAD impalntation

Results Wide range (30% 70%) Five years survival of 30 days survivors 63% Length of support (golden period 3 5 days)

Beilinson Experience 9/08 6/13 CARDIAC N= 54 Myocarditis Ac. MI Post Cardiotomy Post HTx 18 10 9 Post LVAD Other 4 5 8

Beilinson Experience 9/08 6/13 COMPLICATIONS Bleeding Cerebral bleeding Technical 2 3 1 Infection 6 3 Limb Ischemia

Beilinson Experience 9/08 6/13 Cardiac N* Weaned Early Survival 54 38 (70%) 23 (43%) *14 (26%) transported from different hospitals

Case Presentation#1 CARDIAC Male, 21 years old Fever and abdominal pain for 3 days Pulmonary edema and cardiogenic shock Diffuse ST changes Normal coronaries by cath. Myocarditis? Influenza A Transferred with IABP under massive inotropic support

ECMO Placed on Veno Arterial ECMO (28/04/10) Extubation (29/04/10) Removal of ECMO (3/05/10) Doing Well

ECHO Pre ECHO 2 weeks Post

Case Presentation#2 CARDIAC Male, 44 years old Extensive anterior wall MI (late arrival) Emergency PCI to LAD (total ostial LAD) Severe LV Progressive cardiogenic shock IABP, inotropic support, temp pacemaker, mechanical ventilation

The patient was connected to VA ECMO 13/3/13 Extubated a day later Weaned from ECMO after 8 days Discharged home after 24 days

ECHO Pre ECHO Post

Case Presentation#3 CARDIAC Male, 63 years old Extensive anterior wall MI (late arrival) VF, CPR, Mechanical ventilation Emergency PCI to LAD, D and later to RCA Severe LV Progressive cardiogenic shock IABP, inotropic support.

A dedicated team went to the other hospital The patient was connected to VA ECMO and transferred to Beilinson 5/11/12 Multiorgan failure Organ recovery Weaned from ECMO after 7 days Discharged home

ECHO Pre ECHO Post

Followed in our heart failure clinic Developed progressive CHF Implanted with LVAD (HeartMate II) as bridge to transplant 6 months later Doing well

Case Presentation#4 CARDIAC Male, 23 years old Admitted in cardiogenic shock to a another hospital Severe LV dysfunction Giant aneurysm of distal LM and LAD with occlusion of LAD, Cx and communication with LV Underwent surgical correction Connected to central ECMO and chest was left open We were consulted

A dedicated team went to the other hospital The patient was transferred to our OR and ECMO was changed to temporary LVAD (CentriMag) 13/5/13 Multiorgan failure Organ recovery Weaned from LVAD after 16 days Recovering

ECHO Pre ECHO 2 weeks Post

During support After

ECLS is an important technology to support patients in acute cardio-respiratory failure It is prudent to use it early to increase success rate Thank You!