Echo assessment of patients with an ECMO device

Echo assessment of patients with an ECMO device Evangelos Leontiadis Cardiologist 1st Cardiology Dept. Onassis Cardiac Surgery Center Athens, Greece

Gibbon HLM 1953

Goldstein DJ et al, NEJM 1998; 339:1522

Temporary MCS

Mechanical Circulatory Support Systems LEVITRONIX ECMO IABP VAD TAH Electric pumps Pneumatic pumps Rotary pumps

Selection of patients for LVAD implantation Goldstein DJ et al, NEJM 1998; 339:1522

Extracorporeal Life Support (ECLS) Extracorporeal membrane oxygenation (ECMO ) ECMO is instituted as ultima ratio for the management of life threatening respiratory failure or cardiac failure or both ECMO is essentially a modification of the cardiopulmonary bypass circuit used routinely in cardiac surgery

The ECMO circuit Centrifugal pump Hollow-fiber membrane oxygenator with an integrated heat exchange system Heat exchanger

The ECMO design CLOSED circuit (no reservoir) Blood is removed from the venous system Peripherally (femoral vein) Centrally (Cannulation of the right atrium) Blood is oxygenated and CO2 extracted Blood is then returned back to the body Peripherally (femoral artery) Centrally (Cannulation of the Ao. Asc)

Left heart decompression

Right heart decompression

VA (Veno-Arterial)-ECMO Hemodynamically UNSTABLE pts Blood drained from the venous system and returned to the arterial system Provides both cardiac and respiratory support Peripheral or central cannulation

VV (Veno-Venous)-ECMO Hemodynamically STABLE pts Blood drained from the venous system and returned to the venous system Only provides oxygenationrespiratory support Peripheral cannulation (usually both femoral veins)

DESTINATION THERAPY Mechanical Circulatory Support Bridge To Bridge BTR Recovery of myocardial function expected (myocarditis, RV failure after LVAD implantation ) BTT Listed patients for HTx Low-Output Syndrome (inotropic dependent, failure to wean within 7days) ± IABP Pending multiorgan failure Weaning/VAD removal

ECMO for Bridge to Bridge Patients in severe cardiogenic shock of different etiology requiring short-term MCS (usually < 4 weeks). They are usually young patients (age < 60y) in refractory cardiogenic shock (Cardiac Index < 2.2L/min/m², SBP < 90 mmhg, PCWP > 20 mmhg) +/- IABP > 2 Inotropes coming from referral hospitals and have unclear neurological status and end organ function Short-term support devices are the devices of choice for BTB (Centrifugal pumps, Abiomed BV S5000...)

INDICATIONS FOR ECMO Cardiac Failure Post cardiotomy syndrome Post HTX (early graft failure) RV failure after LVAD/HTX Severe heart failure Decompensated cardiomyopathy Myocarditis ACS cardiogenic shock Peripartum cardiomyopahty Sepsis, drug intoxication Respiratory failure ARDS (adult respiratory distress syndrome) Pneumonia Trauma Post LTX (early graft failure) Meconium aspiration Congenital diaphragmatic hernia

Centrifugal Pump-ECMO (since 1987) Simple Cheap Easy to assemble rapidly Portable ECMO team No need for sternotomy (usually femoral cannulation)

Levitronix Extracorporeal, single use, centrifugal pump, continuous flow Can be attached easily to CPB cannulas already in place No mechanical bearings or seals (the motor levitates magnetically the impeller thus rotating with no friction or rub), fast preparation for use Up to 14 days for postcardiotomy syndrome 1500-5500 rpm, flow up to 9.9 l/min No hemolysis, no thrombus formation

JHLT 2009;28:971

Extubated ECMO Patients

Abiomed BVS 5000 (since 1985) Extracorporeal, pneumatic, pulsatile flow, short term (< 10 days), L-R-BVAD BVS 5000: 1 st VAD for postcardiotomy syndrome (FDA) + BTB, BTT The pump fills with blood with gravitational force High thrombogenicity, limited patient mobility 71 pts in cardiogenic shock, 41 % weaned, 11% BTB, 10% BTT, overall survival 62% (weaned, BTB, BTT) (Morgan JA, ASAIO 2004;50:360)

Biomedicus Biopump (since early 1980 s) Uni/B-VAD Extracorporeal, prototypical of centrifugal pumps 2 models (80 ml max. 10 Lt/min, 45 ml for children) Rotating concentric cones generate continuous flow, pump is magnetically coupled to the driver console

Tandem Heart NO difference in 30-day survival and severe adverse events between the 2 groups Percutaneous (Biomedicus cannula 15-17 F), LVAD continuous flow Short-term support Small blood pump, transseptal approach, arterial cannulas, controller Magnetically driven rotor supported by a fluidlubricated bearing 3000-7500 rpm max. 4 Lt/min Burkhoff D et al, Am Heart J 2006; 152:469

Impella R-L-VAD, short term support (max. 7 days) Impeller pump located within a catheter Unloading of ventricle, reduces the myocardial workload and O2 consumption, increases cardiac output Impella LP 2.5 (percutaneous, 2.5 Lt/min @ 50000 rpm), Impella LP 5.0 (small cut-down of femoral artery, 5 Lt/min @ 33000 rpm Hemolysis possible First clinical results (12 pts) show promising results (Garatti A et al, Artif Organs 2006;30:523)

IABP if pt haemodynamically unstable After IABP, ECMO considered in case of haemodynamic instability for potential recovery after revascularization No recovery LVAD/BIVAD as BTR/BTT ( if no neurological deficits)

PERCUTANEOUS 10 pts 5.8 days on Centrimag ECMO support 60% survival to discharge Haemodynamic-clinical improvement after 48 hrs 3.5-5 l/min @ 3500-4500 rpm WEANING CRITERIA Minimal inotropic support LVEF > 30% No evidence of volume overload Haemodynamic criteria CI >2.4 l/min/m² MAP > 60 mmhg PCW < 18 mmhg CVP < 18 mmhg

29 pts Mid sternotomy and Cardiopulmonary bypass Ind: Post-cardiotomy, HTX, LVAD Mean support 8 ± 8 days WEANING- Signs of RV recovery No need for escalation of inotropic therapy Increased amplitude of PA waveform Low CVP Improved RV function (echocardiography) Successful weaning in 66% of pts Early death (<30 days or before discharge) in 48 % of pts JHLT 2009;28:971

Prospective study (975 pts) In-hospital cardiac arrest, CPR>10 min 113 ECPR, 59 CCPR ECMO instituted if no sustained spontaneous circulation after 20 min of CPR Biopump centrifugal pump with membrane oxygenator Results ECPR higher survival rate to discharge ECPR better 1-year survival Lancet 2008;372:554

Management after ECMO insertion First 24 hrs on ECMO Stabilization of flow/anticoagulation (iv heparine) 2-7 days on ECMO Neurologic deficits? Cardiac recovery? LV unloading? Weaning evaluation After day 7 on ECMO VAD implantation? Anticoagulation (i.v heparin infusion for ACT 180-200 sec) Haematocrit should be at 40-45%( maximal 02 delivery), anemia is poorly tolerated

Weaning evaluation Pts on inotropic therapy (milrinone, Dobutamine ) Signs of cardiac recovery Increasing Blood pressure Returning or increasing pulsatility of the arterial pressure waveform Falling po2 (arterial line) Indicating more blood being pumped through the heart which may be less oxygenated Maintenance of Cardiac index, low PCW and LV dimensions (Right heart catheterization) Improved contractility (echocardiography) WEANING likely

Weaning evaluation for ECMOthe importance of afterload LVEF (under ECMO) LVEF but BP LVEF and BP / NO RECOVERY RECOVERY ECMO removal

Complications Bleeding (full heparinization!) Thrombocytopenia PLTs adhere at surface fibrinogen and activated aggregation/clumping PLT Technical/mechanical failure Neurologic sequalae Air embolism/ thromboembolism Leg ischemia (peripheral insertion of ECMO)

Acute RV dysfunction after VAD/HTx Levitronix BiVAD

Graft failure 5 yrs after HTx Levitronix as Bridge-To-Bridge

Conclusions ECMO is instituted for the management of life threatening respiratory or cardiac failure or both when conservative treatment proves ineffective ECMO is a modification of the Cardiopulmonary bypass circuit used for cardiac surgery TTE/TEE (together with right heart catheterization) is the most useful tool in the management and decision making of patients with an ECMO device