ECMO as a bridge to durable LVAD therapy pdf/… · ECMO as a bridge to durable LVAD therapy...
Transcript of ECMO as a bridge to durable LVAD therapy pdf/… · ECMO as a bridge to durable LVAD therapy...
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ECMO as a bridge to durable LVAD therapy
Jonathan Haft, MDDepartment of Cardiac Surgery
University of Michigan
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Systolic Heart Failure
• Prevalence 4.8 million U.S.
• 287,000 deaths per year• $39 billion spent on CHF• Survival outlook <5 years• 550,000 new cases per
year• Aging population• Rise in incidence of
diabetes and obesity
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Ventricular Assist Devices
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Ventricular Assist Devices
• Standard of care as bridge to transplant
• Increasingly utilized as destination therapy
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INTERMACS Level
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Importance of Intermacs Level
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Possible to Downgrade INTERMACS Levels?
• Temporary mechanical circulatory support• Less expensive• Easier to implant
• Peripheral insertion
• Restores circulatory stability and end organ perfusion• May allow end organ recovery• Permits time to better assess patients candidacy for durable LVAD
• Medically• Psychologically• Socially
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Temporary Mechanical Support Systems
• Peripheral VADs• Impella (Abiomed, Inc. Danvers, MA)• TandemHeart (Cardiac Assist, Pittsburgh, PA)
• Temporary surgical VADs• Abiomed BVS(Abiomed, Inc. Danvers, MA)• CentriMag (Thoratec, Inc. Pleasanton, CA)
• ECMO
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Patient Populations
Post-cardiotomySupport
Acute heart failure/cardiogenic
shock
Chronic decompensated heart failure
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When to Offer Temporary Mechanical Circulatory Support
Typically if you’re thinking about it you should probably do it
Delay in initiation leads to deathProlonged CPRElevated lactate
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When not to offer support• Bridge to what?
• Recovery• AMI, postcardiotomy,
myocarditis• VAD/transplant
• Chronic heart failure
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Extracorporeal Membrane Oxygenation
• Modified cardiopulmonary bypass
• No blood:air interface• No venous reservoir• No cardiotomy suction
• Reduces inflammatory response• Reduces requirements for
anticoagulation• VA ECMO
• Cardiac support• VV ECMO
• Respiratory support
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What is in an ECMO Circuit?
Blood pump Oxygenator
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Blood Pumps
• Roller pumps• Hazard cavitation and circuit rupture
• Cone type centrifugal pumps• Thrombus around central bearing• Hemolysis
• Mendler design
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Oxygenators
• Silicone rubber• High resistance• Blood cell activation
• Microporous hollow fibers• Plasma leakage
• Polymethyl Pentene (PMP)• Maquet Quadrox• Medos Hilite
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Integrated Pump/Oxygenator• More easily transportable• User interface simplifies
care• Facilitated prime for rapid
initiation
Cardiohelp (Maquet)
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ELSO Registry Data Summary
July 2016
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21 ELSO Registry July 2016
Active ECLS Centers
0100020003000400050006000700080009000
0
50
100
150
200
250
300
350
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
Num
ber o
f Run
s
Num
ber o
f Cen
ters
Centers
Cases
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22 ELSO Registry July 2016
Runs by Year
0%
20%
40%
60%
80%
100%Card (16 years and over)
Card (1 year < 16 years)
Card (31 days < 1 year)
Card (0 - 30 days)
Adult Pulm
Ped Pulm
Neo Pulm
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23 ELSO Registry July 2016
Adult Respiratory Cases
0
2000
4000
6000
8000
10000
12000
0
500
1000
1500
2000
2500
Cum
ulat
ive
Run
s
Annu
al R
uns
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24 ELSO Registry July 2016
Cardiac Cases By Year16 years old and over
0
2000
4000
6000
8000
10000
12000
0
500
1000
1500
2000
2500
Cum
ulat
ive
case
s
Annu
al c
ases
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25 ELSO Registry July 2016
- 10 20 30 40 50 60 70
1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
16 years old and over
Cumulative Survival in Cardiac Support
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Conduct of ECMO
• Cannulation• Peripheral
• Percutaneous femoral• Expediency• No image guidance necessary
• Surgical• Femoral• Axillary
• Central• Optimal flow• Time consuming• Bleeding• Infectious concerns
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Conduct of ECMO
• Optimize flow to achieve hemodynamic goals• Adjust sweep gas to normalize pCO2
• Patient’s lungs work• Moderate anticoagulation
• ACT, aPTT, Xa, TEG• Lung protective ventilation or extubation• Diuresis or hemofiltration to achieve euvolemia• Minimize sedation• Nutrition• Ambulation?
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Complications: Limb Ischemia
• Ubiquitous problem• Large size cannula
• 15-19 Fr arterial• Coexistent peripheral vascular disease• Vasoconstrictors
• Difficult to assess limb for ischemia• Both legs cold and underperfused• No pulse to doppler
• Failure to recognize and treat will result in limb loss
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• Sensors placed on head and calf• Unilateral fall in rSO2 implies ischemia• 6/17 patients with ischemia (35%)• Resolved with insertion of distal perfusion catheter or fasciotomy• No limbs lost
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“Reperfusion Cannula”
• Additional arterial cannula into leg• Y in with arterial line through luer port in arterial line• “LEGMO”
• Estimated 100cc/min is adequate to maintain viability• Variety of approaches to this strategy
• Open cannulation of SFA (9 Fr wire wound sheath)• Percutaneous cannulation of SFA
• Best if performed prior to insertion of antegrade cannula• Posterior tibial artery (6 or 8 Fr DLP)
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Complications: Left Ventricular Distension
• ECMO is partial bypass• Residual RV output and bronchial flow
• LV must eject to avoid pulmonary edema
• Maintain aortic pulsatility• Follow pulmonary artery pressures• Liberal use of echo
• LV size• Aortic valve opening
• Strategies to facilitate LV ejection• Inotropes (dobutamine, milrinone)• IABP• Control afterload
• Venting when necessary
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Left Ventricular Venting• Transthoracic LV vent
• RSPV• LV apex• PA
• Percutaneous atrial septostomy• TandemHeart drain• Impella as LV vent
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Complications: Harlequin Syndrome
• Femoral VA ECMO• Dysfunctional lungs• Left ventricular ejection
• Diagnose with right hand saturations• Treatment:
• Optimize ventilator• Avoid ventilator induced lung injury
• Convert to VA-V ECMO• Usually occurs in the setting of cardiac
recovery
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Transition to Durable LVAD
Optimization of end organ function
Complications from TMCS
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Evidence
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• Early transition from ECMO to durable support more effective than delayed
• Early = 4 days
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• TMCS were qualitatively different than those not on support
• INTERMACS 2-3 fared better than INTERMACS 1 or TMCS
• No significant differences in survival of TMCS and INTERMACS 1
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Summary
• INTERMACS level 1 patients are at high perioperative risk• Patients in shock can be supported with TMCS
• ECMO utilization grown substantially
• Important limitations of ECMO must be recognized and mitigated• Patients bridged to durable MCS with TMCS remain at elevated risk