IABP to prevent pulmonary edema under VA-ECMO Alain Combes Service de Réanimation ican, Institute of Cardiometabolism and Nutrition Hôpital Pitié-Salpêtrière, AP-HP, Paris Université Pierre et Marie Curie, Paris 6 www.reamedpitie.com
Conflict of interest Principal Investigator: HEROICS trial HVHF after complicated heart surgery NCT01077349 Sponsored by GAMBRO Principal Investigator: EOLIA trial VV ECMO in ARDS NCT01470703 Sponsored MAQUET, Getinge Group Received honoraria from MAQUET, Getinge Group Gambro
Pulmonary edema under VA ECMO
Pulmonary edema Due to an increase in LV afterload created by the backward ECMO flow More frequent With peripheral ECMO If no residual LV ejection Increase in LV afterload Aortic/Mitral regurgitation, LV dilation LV end-diastolic pressure, PCWP Pulmonary edema Laminar flow Alteration of microcirculation?
Pulmonary edema under VA-ECMO
Hemodynamic impact of the IABP Diastolic inflation coronary blood flow myocardial O2 supply myocardial ischemia Systolic deflation afterload et cardiac output myocardial O2 consumption LV work et LV volume Pulsatile blood flow Improvement of microcirculation?
Retrospective study
December 2007 to December 2012 457 peripheral VA-ECMO 90 patients with laminar flow LVEF <15% ITV < 8 cm Δ SBP-DBP <15mmHg
2007-2012 457 PVA ECMO Post-cardiotomy 117 Refractory MOF<48h 96 Chronic pulmonary disease 26 Massive mitral regurgitation 21 Refractory septic shock 14 Femoro-axillary cannulation 10 ARDS 8 Isolate RV dysfunction 8 Prior impella implantation 5 Pulse pressure 15 mmhg 48 or TVI 8 cm IABP for APO 5 APO after IABP explantation 5 ECMO centralisation for other reasons than APO 4 90 patients No-IABP 56 IABP 34
Patients s characteristics Parameter No-IABP IABP Median (25 th -75 th ) n=56 n=34 p Age, y 46,5 (32-54) 51,5 (43-59,5) * 0,02 Male, % 57 % 73 % 0,12 BMI 24,6 (20,6-27,8) 26,6 (24,8-30,7) * 0,02 Charlson score 2 (1-3) 2 (1-3) 0,14 Year 2009 (2008-2010) 2011 (2010-2012) ***p<0,0001 Saps-II score 65 (56-72,5) 75 (54-81) 0,11 SOFA score 11 (6,5-13) 11 (8-14,5) 0,39 Etiology, % Cardiac arrest AMI Myocarditis DCM 28,5% 35,7% 32,1% 32,1% 41,1% 64,7% 11,7% 23,5% 0,22 ** 0,007 *0,03 0,38 Inotrope score, g/kg/min 76,5 (41-127,5) 49 (30-77) *0,03 LVEF, % 10 (7-10) 10 (6-11) 0,73 TVI, cm 4 (2-5) 4 (2-5) 0,38 Mechanical ventilation, % 87,5 % 94,1 % 0,42 PaO2/FiO2 ratio 270 (155-326) 296 (170-376) 0,69 PEEP, cmh2o 4 (2-5) 4 (4-6) 0,14 ph 7,25 (7,18-7,35) 7,25 (7,12-7,32) 0,40 Lactatemia, mmoles/l 8,0 (5,7-10,9) 7,3 (5,0-11,5) 0,98 Q ECMO, L/min 3,97 (3,33-4,45) 4,22 (3,73-4,61) 0,09
Radiologic component of the LIS Radiologic score 4 3 IABP No IABP 2 1 *** *** *** *** 0 D0 D1 D2 D3 D7 D15 Time from ECMO implantation
Percent survival free from Pulmonary edema 110 100 90 80 70 60 50 40 30 20 10 0 P<0,0001 by Logrank test 0 5 10 15 IABP No-IABP Time (days)
Impact of IABP use 75 50 IABP switch for central ECMO Major pulmonary edema 25 0 2006 2007 2008 2009 2010 2011 2012 2013
Need for central ECMO 100 44.6% vs 5.9% 75 ***, p=0.0001 50 25 0 - + IABP
Independent predictors of pulmonary edema occurrence Variables OR IC 95% P No IABP 18.87 4.3-90.97 <0.0001 ph <7.25 at ECMO initiation Inotropic Score >66 at ECMO initiation 4.47 1.19-16.80 0.027 5.0 1.43-18.87 0.013
Outcomes Parameter Median (25 th -75 th ) No-IABP n=56 IABP n=34 IABP duration, d - 5,5 (3,5-7,5) ECMO duration, d 5 (2,5-7,5) 6 (4-10) 0,06 p Follow-up, % Death under peripheral ECMO Death under central ECMO Death under temporary assistance Myocardial recovery Cardiac transplant Bridge to long term assistance 12,5 14,2 32,1 35,7 17,9 14,3 26,5 0 26,5 35,3 5,9 32,3 0,09-0,57 0,97 0,10 0,04* Weaning from MV under ECMO, % 30,4 38,2 0,44 Time on MV under ECMO, % 100 (66,3-100) 100 (40,4-100) 0,52 ICU mortality, % 35,7 29,4 0,54 ICU duration, d 14 (6-30) 10 (6-21) 0,24 Temporary circulatory assistance duration, d 9 (5,5-13) 6 (4-10) 0,13 Mechanical ventilation duration, d 6 (3-15) 5 (3-12,5) 0,29 RRT duration, d 5,5 (1-42) 2 (0-6) 0,69
Prospective study
Study objectives Evaluate the impact of the combination of Peripheral veno-arterial ECMO Counterpulsation with IABP On general hemodynamics and microcirculation In patients with refractory cardiogenic shock
Methods Prospective monocenter crossover study 12 months-study period 12 patients Admitted for refractory cardiogenic shock requiring emergent peripheral veno-arterial ECMO Low or non-ejecting heart : laminar blood flow Evaluation Evaluation under IABP support, after 30 min interruption and 30 min after restarting the IABP
Evaluation of macrocirculation Clinical parameters Arterial blood pressure Echocardiographic parameters Aortic VTI, LVEF, LVEDD, LVESD E/A and E/Ea ratios, mitral annulus S wave CO, CI Pulmonary artery catheter: PAPs, PAPd, PAPm, PAOP Blood gases
Evaluation of microcirculation Sidestream Dark Field imaging SDF Sublingual videomicroscopy sequences Semi-quantitative and dynamic evaluation of microcirculation
Thenar eminence microcirculation InSpectra StO 2 - NIRS Early indicator of tissular hypoperfusion? Models : arteriopathy, septic shock Parameters : Baseline StO2 Vascular occlusion test VOT : T1, T2 Hyperemia (StO2 overshoot)
Brain microcirculation Equanox Nonin Early indicator of brain hypoperfusion Models : cardiac surgery Parameters : Left and right rso2
Patients characteristics Variable Value Range Age, yr 57 ± 14 28 75 Men, n (%) 9 (75%) SAPS2 79 ± 16 65 106 Before inclusion Days of ECMO 6.3 ± 5.9 1 21 Days of IABP 4.7 ± 4.4 1 17 Diagnosis, n (%) Acute myocardial infarction 8 (67%) Acute valvular dysfunction 2 (17%) Dilated cardiomyopathy 1 (8%) Fulminant myocarditis 1 (8%) During study protocol ECMO flow, L/min 4.3 ± 0.9 3 5.5 Catecholamines Dobutamine (n = 4), µg/kg/min 7.5 ± 3.0 5 10 Norepinephrine (n = 1), mg/h 0,6 Epinephrine (n = 5), mg/h 3.0 ± 4.0 0.35 10 Patients on mechanical ventilation, n (%) 12 (100%)
Hemodynamic data Parameter IABP on IABP off IABP restart P Heart rate 99 ± 21 101 ± 17 103 ± 20 0.07 SBP (mmhg) 103 ± 20 102 ± 20 100 ± 22 0.75 DBP (mmhg) 74 ± 17 88 ± 16 72 ± 16 0.02 MBP (mmhg) 87 ± 14 92 ± 16 84 ± 16 0.06 Pulse pressure (mmhg) 29 ± 22 15 ± 13 29 ± 24 0.02 DBP increase (mmhg) 134 ± 40 125 ± 26
Pulmonary artery catheter Parameter IABP on IABP off IABP restart P SBP, mmhg 24 ± 9 29 ± 11 23 ± 10 0.01 DBP, mmhg 16 ± 7 19 ± 10 16 ± 9 0.04 MBP, mmhg 19 ± 8 24 ± 10 19 ± 9 0.02 PAOP, mmhg 15 ± 8 19 ± 10 15 ± 8 0.01 Central venous oxygen saturation, % 73 ± 11 73 ± 15 75 ± 12 0.43
Pulmonary Artery Occlusion Pressure IABP to prevent pulmonary edema under peripheral ECMO
Echocardiographic data Parameter IABP on IABP off IABP restart P LVEDD (mm) 52 ± 14 55 ± 13 47 ± 13* 0.003 $ LVESD (mm) 50 ± 14 51 ± 13 42 ± 13* 0.05 $ Velocity time integral (mm) 25 ± 13 25 ± 14 26 ± 15 0.85 Cardiac output (l/min) 0.79 ± 0.46 0.77 ± 0.78 0.81 ± 0.74 0.85 Diastolic velocity Transmitral early peak (E) (cm/s) 49 ± 19 61 ± 25 51 ± 26 0.07 Transmitral late (A) (cm/s) 32 ± 13 31 ± 9 31 ± 12 0.10 E/A 1.26 ± 0.38 1.95 ± 0.66 1.33 ± 0.36 0.003 Lateral mitral early annular (Ea) (cm/s) 6.4 ± 2.8 6.4 ± 2.5 5.8 ± 1.9 0.44 E/Ea 8.6 ± 4.0 9.8 ± 2.6 9.2 ± 4.3 0.31 S (cm/s) 4.9 ± 2.5 5.0 ± 2.9 4.9 ± 2.3 0.90
NIRS data Near-infrared spectroscopy IABP on IABP off Thenar IABP restart P Baseline StO 2, % 82 ± 6 79 ± 8 82 ± 6 0.41 Tissue desaturation during VOT, (%/s) 0.13 ± 0.06 0.13 ± 0.06 0.14 ± 0.08 0.56 Range 0.04; 0.23 0.02; 0.24 0.03; 0.28 Tissue resaturation after VOT (%/s) 1.26 ± 0.76 1.28 ± 0.70 1.28 ± 0.58 0.21 Range 0.56; 3.20 0.67;2.55 0.57;2.95 Cerebral hemisphere rso 2 Right, % 69.1 ± 5.3 69.4 ± 5.1 69.9 ± 5.3 0.76 Left, % 67.4 ± 5.5 68.6 ± 4.0 68.9 ± 5.3 0.24
PV (%) neity index MFI Heterogeneity index PPV (%) FCD (cm/cm² PPV (%) MFI 300 50 200 0 SDF sublingual imaging 50 0 100 50 0 100 IABP on IABP off IABP on again IABP on IABP off IABP on again 50
If Pulmonary edema occurs
Impella 5.0
Conclusion For cardiogenic shock patients with little/no residual LV ejection while on peripheral VA-ECMO Restoring pulsatility and decreasing LV afterload with IABP Associated with smaller LV dimensions and lower pulmonary artery pressures But no impact on microcirculation parameters IABP might prevent severe hydrostatic pulmonary edema in this context
May 21-24 2014