ECLS as Bridge to Transplant - Critical Care Canada...
Transcript of ECLS as Bridge to Transplant - Critical Care Canada...
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Marcelo Cypel MD, MScAssistant Professor of Surgery
Division of Thoracic Surgery
Toronto General Hospital
University of Toronto
ECLS as Bridge to Transplant
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Application of ECLS
• Bridge to lung recovery in ARDS/ALI
• Bridge to lung transplantation
• Bridge to recovery from primary graft dysfunction
• Cardiogenic Shock
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Diagnosis Age Mode SiteExtubated on
deviceSwitch modes Switch modes 2 Days on Device ECLS post Tx
Discharge hospital
PAH 21 VA F-F 2 y
IPF 62 AV F-F 8 Y y
IPF 55 VV F-J 6 Y y
CF 19 AV F-F VA 2 Y y
CF 49 AV F-F 4 Y n
PAH 40 PA-LA PA-LA 21 y
PAH 16 PA-LA PA-LA Y 30 y
Sarcoidosis/PAH 52 PA-LA PA-LA 10 y
BO 19 AV F-F VA VVA 12 y
Eissenmenger's /PAH 24 VA F-F 3 Y n
CF 30 AV F-F 3 y
PAH 30 PA-LA PA-LA Y 28 Y y
PAH 48 PA-LA PA-LA 8 y
CF 27 AV F-F VA VVA 21 n
IPF 28 AV F-F Y 5 y
PAH 17 PA-LA PA-LA Y 60 Y n
PVOD/PAH 11 PA-LA PA-LA Y 174 Yn
PAH 31 PA-LA PA-LA VA+PA-LA 38 Y y
scleroderma/PAH 48 PA-LA PA-LA Y 7 y
CF 25 AV F-F 5 Y
LAM 46 VV J Y 8 Y
PAH 42 VA F-F Y 2 Y Y
IPF 34 VV F-F Y 21 Y Y
CF 32 VV J 19 Y In hospital
BOS 46 VV J Y 26 Y In hospital
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Bridge to Lung Transplantation
Extracorporeal life support as a bridge to lung transplantation.
Cypel M, Keshavjee S.; Clin Chest Med. 2011 Jun;32(2):245-51
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0 365 730 1095 1460 18250
20
40
60
80
100All LTx
ECLS
p=0.13
Days after transplantation
Perc
en
t su
rviv
al
Figure 1
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Advancements in ECLS Technology
ECLS
Membrane Gas
Exchanger
Tubing CircuitsPumps
Cannulas
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Membranes
Quadrox Novalung
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PUMPS
Rotaflow (Maquet) Centrimag (Thoratec)
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Cannulas (AvalonR)
• One canula inserted through right internal jugular vein
• Drainage from IVC and SVC oxygenated blood returned to right atrium
• Allows mobilisation of extubated patients
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Successful ECLS bridge to LTx
1) Avoid pre-ECLS prolonged mechanical ventilation!
2) Provide adequate mechanical support
3) Avoid groin cannulation if possible
4) Have an engaged AND persistent multidisciplinary team
5) Consider early tracheostomy and nutritional support
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Successful ECLS bridge to LTx
1) Avoid pre-ECMO prolonged mechanical ventilation!
2) Provide adequate mechanical support
3) Avoid groin cannulation if possible
4) Have an engaged AND persistent multidisciplinary team
5) Consider early tracheostomy and nutritional support
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“There is nothing more helpless than to sit at the bedside of a patient, adjusting ventilator settings while the severity of respiratory failure continues to worsen”.
Hubmayr and Farmer, Chest 2010;137:745
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• Injurious mechanical ventilation should be avoided!
•Typical comment: “who cares if the lungs will be replaced”
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Imai/Sltusky, JAMA 2003
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Learning experience from ARDS ECMO experience
• Historical Reports have demonstrated dismal outcomes in patients on prolonged high pressure mechanical ventilation prior to or during ECMO.
• > 7 days on mechanical ventilation precludes ECMO candidacy
(CESAR trial and EOLIA trial)
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Successful ECLS bridge to LTx
1) Avoid pre-ECMO prolonged mechanical ventilation!
2) Provide adequate mechanical support
3) Avoid groin cannulation if possible
4) Have an engaged AND persistent multidisciplinary team
5) Consider early tracheostomy and nutritional support
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ECLS Modes
•Pump (supported)- Veno - venous (V-V)
- Veno - arterial (V-A)
- Hybrid Veno - venoarterial (V-VA)
•Pumpless (pump is patient’s heart)- Arterio-venous (A-V)
- Pulmonary artery to left atrium (PA-LA)
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Cypel/Keshavjee ECMO Red Book 4th edition
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Hypercapnic Respiratory Failure
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AV (Pumpless)
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NovalungPumpless Mode – Femoral Artery to
Femoral Vein (extra-corporeal ventilation)
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AV pumpless
• Excellent mode for hypercapnic respiratory failure and acidosis
• Blood flow through the device: 15-20% CO
• Prompt CO2 clearance but does not improve oxygenation
• Maintenance less demanding than pump ECLS modes
• Contra-indicated in severe hypoxia or unstable hemodynamics
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Initial Experience with Novalung as a Bridge to
Lung Transplantation – Hannover Medical School
Fischer et al. J Thor Cardiovasc Surg 2006;131(3):719
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Limitations of AV Novalung
1) Need of arterial cannulation (increased risk of bleeding and ischemic complications compared to VV)
2) Groin cannulation prevents ambulation
3) Limited support – respiratory failure usually progress to hypoxia requiring switching of ECLS configuration.
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Novalung iLAactive
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Hypoxemic Respiratory Failure
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VV ECMO
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VV ECLS
• Hypercapnia and hypoxemia with stable hemodynamics
• The most common mode of ECLS used for lung failure
• Femoral vein (drain) and Jugular vein (return) or dual lumen Jugular vein
• Ratio of mixed blood ecmo/patient blood is 3/1. Central sats 80-95% (depending on lung contribution)
• Significantly less complications compared to VA ECLS
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VV ECLS
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Avalon Elite™ Bi-Caval Dual Lumen
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Clinical Case
• 46 y female
•LAM
•Admitted to hospital – deterioration – BiPAP
•Mechanical Ventilation – Cardiac Arrest due to tension pneumothorax
•CPR + chest tube insertion
•VV ECMO inserted
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Guided by Fluoroscopy
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25 days after LTx
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Another case……
•34 F
•Pulmonary Fibrosis
•Assessed for LTx but not listed
•Acute Deterioration
• Intubated – 100% FiO2 – Sats 70 - 75% for 2 hours
•Underwent urgent VV ECLS
•25 days on support extubated prior to LTx
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24hs later…
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18 days on ECMO….
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60 days post transplant
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Diagnosis Age Mode SiteExtubated
on deviceSwitch modes
Switch modes
2
Days on
Device ECLS post Tx
Discharge
hospital
PAH 21 VA F-F 2 y
IPF 62 AV F-F 8 Y y
IPF 55 VV F-J 6 Y y
CF 19 AV F-F VA 2 Y y
CF 49 AV F-F 4 Y n
PAH 40 PA-LA PA-LA 21 y
PAH 16 PA-LA PA-LA Y 30 y
Sarcoidosis/PAH 52 PA-LA PA-LA 10 y
BO 19 AV F-F VA VVA 12 y
Eissenmenger's /PAH 24 VA F-F 3 Y n
CF 30 AV F-F 3 y
PAH 30 PA-LA PA-LA Y 28 Y y
PAH 48 PA-LA PA-LA 8 y
CF 27 AV F-F VA VVA 21 n
IPF 28 AV F-F Y 5 y
PAH 17 PA-LA PA-LA Y 60 Y n
PVOD/PAH 11 PA-LA PA-LA Y 174 Yn
PAH 31 PA-LA PA-LA VA+PA-LA 38 Y y
scleroderma/PAH 48 PA-LA PA-LA Y 7 y
CF 25 AV F-F 5 Y
LAM 46 VV J Y 8 Y
PAH 42 VA F-F Y 2 Y Y
IPF 34 VV F-F Y 21 Y Y
CF 32 VV J 19 Y In hospital
BOS 46 VV J Y 26 Y In hospital
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VA ECMO
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VA ECMO
• Severe hypoxemia AND hemodynamic compromise
• Mode of choice for cardiogenic shock
• Excellent central oxygenation is provided if central cannulation is performed (axillary/carotid artery)
• Central hypoxia often occurs if femoral artery is used –NOT a good support for lung failure
• V-VA (infusing blood also to RA) can correct this
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Pulmonary Hypertension and RV Failure
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Pulmonary Hypertension
•High wait list mortality
•Death: Severe Right Heart failure / arrhythmia
•Bridging options – limited efficacy
• PG /vasodilators etc.
• Atrial septostomy trade-off pressure
decompression with systemic hypoxia
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PAH – Support Options
1)PA-LA Novalung (pumpless)2) VA ECM03) VV ECMO if ASD or septostomy
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Novalung PA to LABridge to Lung Transplant for PAH Patients
“The Oxygenating Septostomy”
PA LA
1. Pumpless
2. Effectively: an oxygenating shunt provides pressure
decompression AND gas exchange
Strueber / Keshavjee et al. Am J Transplant 2009; 9: 853-7.
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Insertion of PA-LA Novalung
• Patient brought to the operating room
• VA ECMO inserted under local anesthesia through
femoral vessels to stabilize the patient
• Induction of anesthesia
• Sternotomy and insertion of LA and PA cannulas
• VA ECMO weaned
• Drainage and sternotomy closure
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Novalung PA to LABridge to Lung Transplant
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Novalung PA-LA: Bridge to lung transplant
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June 2008
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Dec 2008
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ECLS decreases wait list mortality in iPAH patients: Toronto experience
0
5
10
15
20
25
1998-2005 2006-2010
Patients listed
Patients transplanted
Died on waiting list
p=0.03
Nu
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de Perrot et al J Heart Lung Transplant 2011
Wait list mortality: 22% 0%
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VA ECMO for PAH
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Olsson, AJT 2010
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VA ECMO “Sport Mode” Jugular Vein - Subclavian Artery
Javidfar J, Bacchetta M. Curr Opin Organ Transplant. 2012 Oct;17(5):496-502.
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Ambulatory ECMO
1) Avoid pre-ECMO prolonged mechanical ventilation!
2) Provide adequate mechanical support
3) Avoid groin cannulation if possible
4) Have an engaged AND persistent multidisciplinary team
5) Consider early tracheostomy and nutritional support
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Critical Care, 2011
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Success depends on ECLS team effort
(1) ECLS/Transplant surgeon
(2) Critical care physician
(3) Perfusionist
(4) Transplant respirologist
(5) ECMO dedicated and trained nurses, pharmacists, respiratory therapist, nutritionists, physical therapist
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Summary
• Artificial lung technology has significantly improved in the last years.
• Better understanding of ECLS physiology have improved patient outcomes.
• Single cannula VV ECMO is the ideal mode for lung failure – decreased complications and allow patient mobilization. It might be the mode of choice for almost all BTT patients in near future.
• Consider ECLS early in the course of respiratory failure.