VA-ECMO

XXXV Congresso Português de Cardiologia
April 28, 2014 - 11:00-12:30
Albufeira, PORTUGAL
Short-Term Mechanical
Circulatory Support
after the IABP-SHOCK II Trial
Roberto Roncon-Albuquerque Jr, MD PhD
Department of Intensive Care Medicine - Centro Hospitalar S.João
Department of Physiology and Cardiothoracic Surgery - Faculty of Medicine of Porto
Porto, PORTUGAL
Abstract
1. From SHOCK to IABP-SHOCK II.
2. Profound CS: definition and initial approach.
3. Current options for ST-MCS.
4. Current indications for VA-ECMO.
5. The MUCA concept.
2
Abstract
1. From SHOCK to IABP-SHOCK II.
2. Profound CS: definition and initial approach.
3. Current options for ST-MCS.
4. Current indications for VA-ECMO.
5. The MUCA concept.
3
The SHOCK Trial
4
The SHOCK Trial
•
302 patients with post-AMI-LV-CS randomly assigned to
‘emergency’ revascularization vs. initial medical stabilization.
•
‘Emergency’ revascularization (n=152): CABG or PCI required
within 6 hours of randomization.
•
Initial medical stabilization (n=150): delayed
revascularization at least 54 hours post-randomization.
•
Primary endpoint: 30-day all-cause mortality.
5
The SHOCK Trial
Primary endpoint: 30-day mortality
Hochman JS et al. N Engl J Med 1999;9:625-34.
6
The SHOCK Trial
•
Although there was no significant benefit at 30 days, ERV
was superior to IMS at 6 and 12 months of follow-up.
•
In the ERV, 64% underwent PCI and 36% underwent CABG.
•
In the ERV, mortality was similar in PCI and CABG groups.
•
IABP was used in 86% of patients (similar in ERV and IMS
groups).
7
The IABP-SHOCK I Trial
8
The IABP-SHOCK I Trial
•
45 patients with CS complicating AMI undergoing early
revascularization were randomized to treatment with or
without IABP.
•
APACHE II scores, hemodynamic values, inflammatory
markers and plasma BNP levels were collected over 4 days
from randomization.
•
Hypothesis: adding IABP therapy to ‘standard care’ would
improve CS-triggered MODS.
•
Primary endpoint: improved APACHE II scores in IABP group.
9
The IABP-SHOCK I Trial
APACHE II
CI
BNP
IL-6
Prondzinsky R et al. Crit Care Med 2010;38:152-60.
10
The IABP-SHOCK I Trial
•
IABP support was associated only with modest effects on
reduction of APACHE II score in patients with CS complicating
AMI submitted to early revascularization.
•
IABP support also did not have a significant impact on
cardiac index or systemic inflammatory activation, although
BNP levels were significant lower.
•
The major limitations of the IABP-SHOCK I Trial requested for
a larger multicentered RCT with mortality as primary
endpoint.
11
The IABP-SHOCK II Trial
12
The IABP-SHOCK II Trial
•
600 patients with CS complicating AMI were randomized to
treatment with or without IABP.
•
All patients were expected to undergo early
revascularization (primary PCI or CABG) and to receive the
best available medical therapy.
•
Primary endpoint: 30-day all-cause mortality.
•
Multicenter RCT conducted at 37 German medical centers.
13
The IABP-SHOCK II Trial
Primary endpoint: 30-day mortality
Thiele H et al. N Engl J Med 2012;367:1287-96.
14
The IABP-SHOCK II Trial
12 Month Mortality
Thiele H et al. Lancet 2013;382:1638-45.
15
The IABP-SHOCK II Trial
12 Month Follow-Up
Thiele H et al. Lancet 2013;382:1638-45.
16
The IABP-SHOCK II Trial
Quality-of-Life Measures
Thiele H et al. Lancet 2013;382:1638-45.
17
The IABP-SHOCK II Trial
Visual Analogue Scale of Self-Rated Health
Thiele H et al. Lancet 2013;382:1638-45.
18
The IABP-SHOCK II Trial
•
The use of IABP did not significantly reduce mortality in
patients with CS complicating AMI for whom an early
revascularization strategy was planned.
•
For survivors, quality-of-life measures including mobility,
self-care, usual activities, pain or discomfort, and anxiety or
depression did not differ significantly between study groups.
•
The IABP-SHOCK II Trial challenges Level 1 Evidence for the
use of IABP counterpulsation in CS complicating AMI in
current ESC and AHA Guidelines.
19
Abstract
1. From SHOCK to IABP-SHOCK II.
2. Profound CS: definition and initial approach.
3. Current options for ST-MCS.
4. Indications for ST-MCS.
5. The MUCA concept.
20
Profound CS
•
Universal definition not available.
•
Requirement of increasing inotropics despite adequate
fluid management to maintain systolic BP > 90 mmHg
and physiological evidence of visceral hypoperfusion.
Beurtheret S et al. Eur Heart J 2013; 34: 112-20.
•
Systolic BP < 75 mm Hg after IABP and inotropics
Sheu JJ et al. Crit Care Med 2010; 38: 1810-7.
•
IABP score
•
Inotropic score + PWP + Urine output + SvO2
Hausmann H et al. Circulation 2002; 106[suppl I]:I-203-I-6.
21
Profound CS
12-Month Mortality
80%!!!
Tsao NW et al. J Crit Care 2012;27:530.e1-11.
22
ST-MCS: When to Start?
TOO EARLY!!!
Irreversible MOF
ST-MCS Complications
23
ST-MCS: When to Start?
TOO LATE!!!
ST-MCS Complications
Irreversible MOF
24
Refractory CS: HD assessment
Classic Approach: PAC
•
Definition:
Cardiac Index < 2.0-2.2 L  min-1  m-2 and PCWP > 15 mmHg.
Vincent JL. Crit Care 2006;10(Suppl 3):S1.
25
Refractory CS: HD assessment
Transpulmonary Thermodilution
ECLS-HSJ Center; 2014
26
Refractory CS: HD assessment
Point-of-Care TTE
ECLS-HSJ Center; 2013
27
Refractory CS: HD assessment
Point-of-Care Echocardiography (TTE and TEE):
•
Immediate availability at the bedside.
•
Preload / Contractility / Afterload assessment.
•
Mechanical complications / Pericardium.
•
Separate LV and RV function assessment.
•
Guide invasive procedures.
28
Refractory CS: HD assessment
Surrogates of VO2 / DO2 mismatch:
•
SvO2 < 70% >>> PAC required.
•
SvcO2 < 70%
•
Veno-Arterial CO2 Gradient > 6
•
Lactate > 2.0 and Lactate clearance
•
MOF
PAC not required.
29
Refractory CS: HD assessment
Fluid Responsiveness beyond CVP:
•
Subaortic VTI increase after 100 ml colloid >>> TTE required.
•
IVC diameter variation >> TTE required.
•
Passive leg raising >>> TTE, PT or PAC required.
Fluid Responsiveness and Heart-Lung interactions:
•
PPV >>> TTE, PT or PAC not required.
•
EEOT >>> TTE, PT or PAC required.
30
Refractory CS: First Line Inotropes
31
Refractory CS: First Line Vasopressors
De Backer D et al. N Engl J Med 2010;362:779-89.
32
Abstract
1. From SHOCK to IABP-SHOCK II.
2. Profound CS: definition and initial approach.
3. Current options for ST-MCS.
4. Current indications for VA-ECMO.
5. The MUCA concept.
33
Percutaneous Temporary LVAD
• Pro
•
Superior HD support compared with IABP.
•
LV unloading.
•
Implantation in the catheterization laboratory.
• Con
•
Atrial septostomy needed.
•
No respiratory support.
•
Complications: bleeding, thrombosis, leg ischemia and dislocation of
transseptal or atrial cannulas.
34
Percutaneous Temporary LVAD
Image available at texasheart.org/research/devices/tandemheart
35
Percutaneous Temporary LVAD
Thiele H et al. Eur Heart J 2005;26:1276-83.
36
Micro-Axial Pumps
• Pro
•
Percutaneous insertion and initiation of ST-MCT in the cath. lab.
•
Superior HD support compared with IABP.
•
LV unloading.
• Con
•
Complications: Ao regurgitation, limb ischemia, device displacement.
•
Limited published evidence (no difference in 30-day mortality for
Impella® 2.5 compared with IABP).
•
Very short-term support (hours-to-days).
•
Expensive.
37
Micro-Axial Pumps
Images available at www.abiomed.com/products/impella-2-5/
38
Micro-Axial Pumps
Courtesy of Luis Coentrão. Service de Réanimation Médicale - Institut de Cardiologie - Hôpital Pitié-Salpêtrière, Paris (France)
39
Percutaneous Temporary LVAD
Seyfarth M et al. J Am Coll Cardiol 2008;52:1584–8.
40
Peripheral VA-ECMO
• Pro
•
Bedside percutaneous implantation.
•
Superior HD support compared with IABP and Impella®.
•
LV + RV support.
•
Respiratory support.
• Con
•
Complications: bleeding and limb ischemia.
•
LV unloading (?).
•
Not suited for long-term support.
41
Modern VA-ECMO
Artery
Femoral
Axillary
Arterial Cannula
(15-17 Fr; 15 cm)
Oxygenator
(Sweep: 1-12 LPM)
 O2 /  CO2
Centrifugal Pump
(3.0-8.0 LPM)
Vein
Femoral
Right Internal Jugular
Venous Cannula
(23-25 Fr; 55 cm)
42
Peripheral VA-ECMO: Contraindications
• Cardiovascular
•
Severe aortic regurgitation.
•
Aortic dissection.
• Neurological
•
Prolonged cerebral hypoxia.
•
Intracranial ischemia / hemorrhage.
• Hematological
•
Uncontrolled bleeding.
43
Peripheral VA-ECMO: Complications
•
Leg ischemia
•
•
•
Harlequin syndrome
•
Monitor HbO2 in the right arm / Noninvasive cerebral oximetry.
•
Rest ventilator settings with 50%-FiO2.
Left ventricular distension / Non-ejecting LV
•
•
•
Distal arterial perfusion cannula (?)
LV venting / Impella / Atrial septostomy.
Aortic / LV / RV thrombus
•
Cardiac stun / Non-ejecting heart.
•
Adjust systemic anticoagulation.
Gas embolism
44
Peripheral VA-ECMO: Complications
Risk of
hyperoxia
Risk of
hypoxaemia
Ventilator Settings
MO Settings
Courtesy of Alois Phillip. Department of Cardiothoracic Surgery - University Hospital Regensburg (Germany)
45
VA-ECMO: Complications
Leg Ischemia
Arterial Perforation
Courtesy of Alois Phillip. Department of Cardiothoracic Surgery - University Hospital Regensburg (Germany)
46
Modern VA-ECMO
•
•
Evolution in biomaterials:
•
Centrifugal pumps
•
Heparin-coated circuits and cannulas
•
Polymethylpentene oxygenators
Methodological evolutions:
•
Percutaneous cannulation
•
Miniaturized circuits
•
Ultra-compact mobile ECMO systems
47
The first ECMO machine….
Venous Cannula
(23-25 Fr; 55 cm)
Hill JD & Bramson BME. Santa Barbara (California, USA), 1971
48
ECMO: Bedside percutaneous cannulation
ECLS-HSJ Center; 2013
49
Miniaturized Portable ECMO
ECMO
MV
ECLS-HSJ Center; 2013
50
Ultra-Compact Mobile ECMO
MV
ECMO
Monitor
ECLS-HSJ Center; 2013
51
VV-ECMO: Early Mobilization
Courtesy of Alois Phillip. Department of Cardiothoracic Surgery - University Hospital Regensburg (Germany)
52
VA-ECMO: Early Mobilization
ECLS-HSJ Center; 2014
53
VA-ECMO: Early Mobilization
ECLS-HSJ Center; 2014
54
Awake VV-ECMO
ECLS-HSJ Center; 2014
55
Active Rehabilitation on ECCO2R
ECLS-HSJ Center; 2014
56
Abstract
1. From SHOCK to IABP-SHOCK II.
2. Profound CS: definition and initial approach.
3. Current options for ST-MCS.
4. Current indications for VA-ECMO.
5. The MUCA concept.
57
Current Indications for VA-ECMO
1. Refractory CS complicating AMI.
2. Post-cardiotomy CS.
3. Refractory cardiac arrest.
4. Non-heart beating donor transplantation.
58
Indications for ST-MCS
1. Refractory CS complicating AMI.
2. Post-cardiotomy CS.
3. Refractory cardiac arrest.
4. Non-heart beating donor transplantation.
59
VA-ECMO: Profound CS complicating AMI
60
VA-ECMO: Profound CS complicating AMI
Sheu JJ et al. Crit Care 2010;38:1810-7.
61
VA-ECMO: Profound CS complicating AMI
Sheu JJ et al. Crit Care 2010;38:1810-7.
62
VA-ECMO: Profound CS complicating AMI
63
VA-ECMO: Profound CS complicating AMI
Tsao NW et al. J Crit Care 2012;27:530.e1-11.
64
VA-ECMO: Profound CS complicating AMI
65
VA-ECMO: Profound CS complicating AMI
66
Current Indications for VA-ECMO
1. Refractory CS complicating AMI.
2. Post-cardiotomy CS.
3. Refractory cardiac arrest.
4. Non-heart beating donor transplantation.
67
Post-Cardiotomy CS
Plasmapharesis
HFVVC
MV
Impella®
VA-ECMO
Courtesy of Luis Coentrão. Service de Réanimation Médicale - Institut de Cardiologie - Hôpital Pitié-Salpêtrière, Paris (France)
68
Post-Cardiotomy CS
69
Current Indications for VA-ECMO
1. Refractory CS complicating AMI.
2. Post-cardiotomy CS.
3. Refractory cardiac arrest.
4. Non-heart beating donor transplantation.
70
E-CPR: In-hospital cardiac arrest
71
E-CPR: In-hospital cardiac arrest
72
E-CPR: In-hospital cardiac arrest
Vitale J and Mumoli N. N Engl J Med 2012;368:1260-1.
73
E-CPR: ECMO-assisted PCI
74
E-CPR: ECMO-assisted PCI
75
E-CPR: Out-of-hospital cardiac arrest
Maekawa K et al. Crit Care Med 2013;41:1186-96.
76
E-CPR: Out-of-hospital cardiac arrest
Maekawa K et al. Crit Care Med 2013;41:1186-96.
77
E-CPR
ECLS-HSJ Center; 2014
Abstract
1. From SHOCK to IABP-SHOCK II.
2. Profound CS: definition and initial approach.
3. Current options for ST-MCS.
4. Current indications for VA-ECMO.
5. The MUCA concept.
79
80
ECMO Rescue
40
Patient Number
35
HSJ = 43
Rescue = 39
10/24
30
9/17
25
20
12/8
14/4
15
10
5
4/0
0
2009
2010
2011
Year
HSJ-ECLS Center; 2013.
2012
2013
Referral to ECMO-HSJ
Hospital S.João
Açores
81
The MUCA Concept: Rescue Ambulance
ECLS-HSJ Center; 2013
82
The MUCA Concept: Rescue Helicopter
Courtesy of Alois Phillip. Department of Cardiothoracic Surgery - University Hospital Regensburg (Germany)
83
The MUCA Concept: Rescue Aircraft
ECLS-HSJ Center; 2013
84
The MUCA Concept: Rescue Aircraft
ECLS-HSJ Center; 2013
85
The MUCA Concept
86
The MUCA Concept
Beurtheret S et al. Eur Heart J 2013;34:112-20
87
Final Remarks
•
IABP is no longer a first line treatment in CS complicating
AMI.
•
Currently, ST-MCS is not a first line treatment in CS.
Referral to ST-MCS Centers should be considered in
refractory CS.
•
Modern VA-ECMO can provide immediate biventricular
and respiratory support at the bedside. Current
ESC/ACC/AHA guidelines have no formal
recommendations for VA-ECMO use.
•
MUCAs are needed to provide high-quality ST-MCS at a
national level.
88
Invitation:
First Post-Graduate Course on
ECMO and Short-Term MCS
Cardiovascular Sciences PhD Program
Faculty of Medicine - University of Porto
June, 2014
Obrigado!
89

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