David Spielvogel, MD Surgical Director, Cardiac Transplant and Mechanical Circulatory Support...
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Extracorporeal Membrane Oxygenation (ECMO): Indications and Management Strategy David Spielvogel, MD Surgical Director, Cardiac Transplant and Mechanical Circulatory Support Gilbert Tang, MD, MSc, MBA Cardiothoracic Surgeon, Transcatheter Heart Program On behalf of the Cardiac Transplant and Mechanical Circulatory Support Team Westchester Medical Center, Valhalla, New York
David Spielvogel, MD Surgical Director, Cardiac Transplant and Mechanical Circulatory Support Gilbert Tang, MD, MSc, MBA Cardiothoracic Surgeon, Transcatheter
David Spielvogel, MD Surgical Director, Cardiac Transplant and
Mechanical Circulatory Support Gilbert Tang, MD, MSc, MBA
Cardiothoracic Surgeon, Transcatheter Heart Program On behalf of
the Cardiac Transplant and Mechanical Circulatory Support Team
Westchester Medical Center, Valhalla, New York
Slide 2
OBJECTIVES Understand the clinical indications for ECMO therapy
Identify procedural strategies and techniques of ECMO therapy
Discuss management strategy of ECMO in the ICU Describe the ECMO
experience at Westchester Medical Center
Slide 3
PHYSIOLOGY of ECMO Basic principle : De-saturated blood is
drained via a venous cannula, CO2 is removed, O2 added through an
extracorporeal device (an oxygenator), and the blood is then
returned to systemic circulation via another vein (VV ECMO) or
artery (VA ECMO)
Slide 4
VV ECMO Perfusate blood returned to systemic circulation via
venous cannula travels into right ventricle and next pulmonary
vasculature and is returned to the systemic circulation Volume
removed = volume returned; therefore no net effect on CVP,
ventricular filling, or hemodynamics CO2/O2 content in arterial
blood supply is that of the blood arriving to right ventricle + any
effects from gas exchange from remaining pulmonary function
Slide 5
VA ECMO Replaces/augments both pulmonary and cardiac function
Perfusate mixes in the aorta with blood from left ventricle
(arriving from compromised lungs); thus O2/CO2 content = content of
blood returning from the circuit + that of pulmonary source;
Systemic blood flow = ECMO flow + pts own CO
Slide 6
Role of ECMO in Cardiogenic Shock Bridge to recovery (BTR)
Bridge to decision (BTD) Bridge to surgery Bridge to long-term VAD
Bridge to transplant (BTT)
Slide 7
IABP in Cardiogenic Shock Can initially stabilize patient May
not provide enough support Requires a certain level of LV function
Limited by persistent tachycardia / arrhythmias Does not unload the
RV Provides some pulsatile flow with ECMO
Slide 8
BRIDGE TO RECOVERY Indications Acute MI Acute decompensated HF
Post-cardiotomy syndrome Acute myocarditis Severe rejection in
transplant Takotsubos Massive PE Respiratory failure and ARDS
Slide 9
BRIDGE TO SURGERY Indications Mechanical complications of AMI
VSD Severe MR from papillary muscle rupture CAD requiring CABG
Massive PE with heparin failure
Slide 10
BRIDGE TO Long-term VAD Indications Unable to wean off ECMO
Difficult donor match for transplant Not a transplant candidate
=> LVAD as Destination Therapy
Slide 11
BRIDGE TO TRANSPLANT Indications Unable to wean off ECMO
Transplant candidate Easy donor match for transplant
Slide 12
Predictors of Poor Outcomes Multiorgan dysfunction ARDS with
sepsis Severe neurological injury Long time interval between shock
and initiating ECMO
Slide 13
CONTRAINDICATIONS Major CNS injury Severe anoxia Embolic or
hemorrhagic stroke Intracerebral hemorrhage Multiorgan failure
Metastatic disease Overwhelming sepsis
Slide 14
Slide 15
TWO TYPES OF ECMO: Veno-arterial bypass - supports the heart
and lungs Veno-venous bypass supports the lungs only
CENTRIMAG QUADROX OXYGENATOR IABP PA Catheter Venous:
percutaneous Arterial: Femoral percutaneous Axillary graft Aorta
direct
Slide 21
R axillary artery R femoral vein
Slide 22
Axillary vs Femoral Cannulation AXILLARY FEMORAL Side-arm graft
sewn on Antegrade perfusion better for cerebral and aortic root
oxygenation, especially when lungs not oxygenating Increased
afterload Risk of arm hyper-perfusion Percutaneous Need antegrade
stick for forward perfusion Retrograde perfusion increases
atheroembolic risk Ad-mixing with cardiopulmonary circulation =>
indequate cerebral and aortic root oxygenation if lungs not
oxygenating
Slide 23
Check arterial line pressure! High line pressure risks
hyperperfusion and bleeding at axillary site Need to Y the arterial
outflow: Bi-axillary Axillary + femoral Indications Patients with
large BSA Small axillary artery
Slide 24
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Anticoagulation IV Heparin, target ACT of 200-240 seconds to
prevent clotting upon interference of blood with prosthetic
surfaces and in stagnant areas. If high bleeding risk, ACT 180-220
s Watch for platelet drop and heparin induced thrombocytopenia
(HIT)
Slide 26
Monitoring an ECMO patient Continuous cerebral SaO2 CVP, PAP,
CO CXR assess pulmonary edema SvO2: 75% in VA ECMO and 85-90% on VV
ECMO considered adequate as long as CO normal EtCO2 measures return
of native lung function aBG, lactate tissue perfusion Urine output,
fluid balance renal function Labs: renal, hepatic function Platelet
count
Slide 27
POTENTIAL RISKS Infection Bleeding Brain Surgical site
Non-pulsatile flow Renal insufficiency Peripheral ischemia Limb
complications Arm hyperperfusion Leg ischemia Air in circuit Pump
malfunction Clots in the circuits Heat exchanger malfunction
Cannula dislodgement
ECMO Weaning Protocol ICU ECMO flow down to 1-1.5 L/min for 5
min Assess CVP, PAP, CO TTE to assess LV, RV function OR 3000-5000
U heparin ECMO flow down to 1 L/min Assess CVP, PAP, CO TEE to
assess LV, RV function, septal position Explant ECMO if
appropriate
Slide 30
Special Note on ECMO & LVAD Pts with LVAD need to balance
flow with both LVAD and ECMO to optimize end- organ perfusion TEE
to check septal position, need to unload RV After ECMO explant,
LVAD flow needs to increase b/c of LV preload increases
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Patient CharacteristicsN = 21 (%) Age (mean +/- SD)61 +/- 14
years Female7 (33%) Renal failure1 (5%) COPD2 (10%) PVD4 (19%) TIA
/ Stroke2 (10%) History of MI16 (76%) History of CHF8 (38%)
Cardiogenic shock21 (100%) Prior PCI11 (52%) Prior CABG4 (19%)
Ventricular tachycardiac/fibrillation11 (52%) Cardiac arrest
requiring resuscitation10 (48%) IABP or Impella support prior to
ECMO21 (100%) Predicted mortality from APACHE 4 score (mean +/- SD)
38 +/- 16% - Catheterization laboratory45 +/- 16% - Operating
room36 +/- 16% ACS Shock on ECMO at WMC
Slide 43
Implant DataN = 21 (%) Location of ECMO implant: -
Catheterization laboratory7 (33%) - Operating room14 (67%) Site of
arterial outflow: - Percutaneous femoral (all placed in cath lab)7
(33%) - Axillary (all placed in OR)14 (67%) Duration of support
(mean +/- SD)9.0 +/- 7.5 days OUTCOMES 30-day all-cause mortality5
(24%) 30-day mortality by location of ECMO implant: -
Catheterization laboratory4/7 (57%) - Operating room1/14 (7%) ECMO
as bridge to: - Recovery9 (43%) - CABG5 (24%) - LVAD /
Transplantation2 (10%) Prolonged ventilation10 (48%) Pneumonia3
(14%) Renal failure1 (5%) Stroke1 (5%) Irreversible neurological
injury2 (10%) Multiorgan failure1 (5%) Bleeding2 (10%) Vascular
injury0 (0%)
Slide 44
CONCLUSIONS Rapidly evolving technology Increasing array of
indications Excellent tool for ACS with cardiogenic shock Shifting
the paradigm of bridge to recovery Presently investigating the
science behind the clinical results
