Veno-arterial ECLS for cardiogenic shock
STS Symposium: Mechanical Circulatory Support
for Advanced Cardiopulmonary Disease
September 2013
Chicago
I have no financial interests in any of the
technologies discussed and nothing to disclose
Charles Hoopes MD
University of Kentucky
Questions & learning objectives…ECLS & cardiogenic shock
Is “salvage” ECLS in the patient with cardiopulmonary collapse
an evidence based approach … the clinical rationale for and
clinical limitations of ECMO
What are the physiological goals of ECLS in cardiogenic shock
… what are the biological and clinical markers of success ?
How does “emergent” ECLS in the patient with cardiogenic
shock change the options and the risk profile of subsequent
durable LVAD implantation and transplant ?
“Our interventionists had a case recently where patient had a LAD PCI
then was brought back a couple of days later for a RCA mid lesion. She
arrested on insertion of the catheter in the aortic root -- never did a
manipulation -- and after initial unsuccessful resuscitation, placed an
impella and kept it up. They injected her L and it was open and, while
still arrested opened the mid RCA. They called us after about 45 min
of arrest when she was still in asystole. We then had ECMO there
but by then it was an hour of arrest with no rhythm and felt ECMO
would be futile. Do you have or know of any experience that would
justify a trial of ECMO in this situation. I could understand if it was a
bridge to recovery with severe shock, but with a rhythm -- or if there
was a L main or other proximal lesion to open.”
veno-arterial ECMO/ECLS ?
41 yo male Vfib arrest (in house) … total occlusion
LAD. Acute thrombosis of RCA during LAD PCI …
ventricular arrhythmias with cardioversions x 16.
IABP and Impella 2.5 … transferred to ICU with
patent LAD, recurrent thrombosis of RCA (100%
mid), inotropes. Clotting diathesis … ?
24 hours post cath … CI 1.6, Cr 5.5, AST > 5000,
lactate > 6 …Q’s in II, III, aVF … trops > 50.
Adequate gas exchange …
Return to cath lab … patent LAD, 100% mid RCA …
Vfib
veno-arterial ECMO/ECLS ?
“Defibrillation was attempted again but remained unsuccessful.
CPR continued. We suspected that the patient’s heart was too distended
to permit termination of ventricular fibrillation … a decision was made to
consult cardiac surgery about the initiation of extracorporeal membrane
oxygenation (ECMO) for full hemodynamic support and to decompress the
heart and facilitate termination of ventricular fibrillation.”
n engl j med 369;11 nejm.org september 12, 2013
Pubmed search: “ECMO and cardiogenic shock” …
403 citations (60% w/in the past 60 months)
… the large randomized IABP-Shock II Trial did not show a
significant reduction in 30-day mortality in cardiogenic shock with
IABP insertion.
… both the Impella pump and the Tandem Heart did not reduce 30day mortality when compared with IABP in small randomized
controlled trials
… no randomized study data available for ECMO/ECLS use in
cardiogenic shock
Trends in the incidence
rates of cardiogenic
shock in patients with
acute myocardial infarcts.
Goldberg et al. Thirty-year
trends (1975 to 2005) in the
magnitude of,management of, and
hospital death rates associated
with cardiogenic shock in patients
with acute myocardial infarction
Circulation 2009;119:1211
1 in 20
Trends in hospital case
fatality rates in patients with
acute myocardial infarct
according to the presence of
cardiogenic shock.
40%
Is ECLS the answer ?
30% survival to discharge !
ELSO Registry Jan 2010
Among 98 patients …
cardiogenic shock (34), ventricular fibrillation or pulseless ventricular
tachycardia (23), or asystole /pulseless electrical activity (41)
96% underwent emergency revascularization (2 received CABG)
with successful angioplasty achieved in 71% (TIMI 3 flow)
55% were weaned from ECLS …
ECLS-related complications occurred in 36%... cannulation site bleeding
All-cause in-hospital mortality rate was 67.3%,
and the survival rate to hospital discharge was 32.7%
“ …disappointing results for the sole use of ECLS … aggressive
initiation of ECLS could improve survival rates to 70% to 80% … the
reason for cardiac surgeons to understand its lessons:
Prolonged cardiogenic shock carries a high mortality without a plan
for definitive additional therapy
Revascularization in the setting of cardiogenic
shock provides little or no additional benefit and
in the short term may be detrimental by delaying definitive
support
ECLS is an effective method of early resuscitation of the moribund
patients in shock … its effectiveness depends on end organ ischemic
time, early ventricular recovery, or use of more definitive devices
for long-term support”
Invited Commentary
George L Hicks, MD
University of Rochester Medical Center
“ECMO in advanced refractory AMICS is associated with acceptable
outcomes in a well-selected population.
ischemic 50% at 6 mos
non-ischemic 20%
ECMO in patients with an acute
decompensation of a chronic
cardiomyopathy should be carefully
considered to avoid futile support.”
Kaplan-Meier survival curve of all patients supported on
ECMO for cardiogenic shock (subsequent management
strategies included revascularization, VAD, or heart
transplantation)
Bermudez et al (2011) ECMO for advanced refractory shock in
acute and chronic cardiomyopathy. AnnThorac Surg 92:2125
Cannulation and initiation of flow … vascular access,
gas exchange , and flow
Do what you need to get what you want …
perfusion w/o ischemia
adequate hemodynamics
“viable patient”
Engineering should inform the discussion
around patient care …
“Thought algorithms” vs “protocols”
ECMO: simple operation, complex procedure
“Truisms” about ECLS/ECMO …
ECMO resuscitates the moribound … it cannot reanimate the dead
… question of patient viability or myocardial recovery
ECMO remains a non-durable technology …
ECLS is a simple procedure, extracorporeal technologies
are a complex management paradigm
ECLS accomplishes nothing (it is non-therapeutic), but
facilitates everything
Two types of ECMO/ECLS program … public health perspective …
clinical goals define infrastructure (technology and personnel)
Acute stabilization and short term transfer
“moratorium of decision” programs (in house … cath lab, ED, OR)
duration of support < 72 hrs, limited infrastructure
rapid deployment technology (non-durable technologies)
Integrated programs (ICU and/or transplant)
“recovery” and “bridge to transplant” (referral based)
duration of support > 72 hrs, extended infrastructure (MCS)
durable technologies (“ambulatory ECMO”)
… institutional culture and hospital
structure impact on ECLS program
design
The 30-day mortality rate in
patients with witnessed OHCA
undergoing ECLS treatment
can be significantly improved
if ECLS support is established
within the first 30 min after
admission …rdECMO
Leick et al (2013) Door-to-implantation time of extracorporeal life support systems predicts
mortality in patients with out-of-hospital cardiac arrest. Clin Resarch Cardiol 102:661.
Sheu et al (2010) ECMO assisted primary percutaneous coronary intervention
improved 30-day clinical outcomes in patients with ST-segment elevation
myocardial infarction complicated with profound cardiogenic shock. Crit Care
Med 38:1810.
Basic ECMO…
Cannulation...clinical need determines strategy
femoral vein to IJ (traditional VV)
femoral vein to femoral artery (traditional VA)
femoral vein and RIJ to femoral artery (VVA)
RIJ dual lumen and subclavian artery (“walking hybrid”)
RA to Ao (central VA)..”ambulatory CPB” (VAD)
RA to PA…right heart bypass (VAD)
PA to LA…right heart bypass (VAD)
RIJ dual lumen cannula (VV Avalon DLC)
RIJ dual lumen and femoral artery (VVA “sedate hybrid”)
femoral artery to RA (AV) …reverse
“pumpless” arterio-venous cannulation (pECLA)
Membrane oxygenator (Quadrox)
Centrifugal blood pump (Centrimag or Rotaflow),
roller pump, or “native flow” (cardiac output)
Anticoagulation (heparin ACT “point of care”, TEG)
Personnel (MCS service line or ECMO specialists)
Cardiopulmonary collapse (circulatory arrest)
CPR
“salvage” ECLS
“moratorium of decision” … end organ injury
“bridge to recovery” … myocardial injury
(…application and
deployment)
“bridge to definitive therapy” … non-durable to durable support
“emergent” ECLS
Cardiogenic shock (INTERMACs I)
Cannulation …
Peripheral veno-arterial ECLS
RA/femoral vein…retrograde femoral a. (ECMO)
RA…antegrade right subclavian a. (8mm Dacron graft/ECMO)
LA/femoral trans-septal …retrograde femoral a.
Central veno-arterial ECLS
RA to pulmonary a. (right heart)
LA to aorta (VAD)
RA to aorta (ECMO)
(…application and
deployment)
Femoral cannulation for veno-arterial (VA) ECMO …
RA/IVC drainage from CFV access (23/25F)
…venous return limits flow
Arterial inflow (17F) … “downsize”
Distal arterial inflow (6F) … “downsize”
…“open” versus “percutaneous” access ?
*no complications
*exit strategy
VAda ECMO
VenoArterial (distal artery)
ECMO
Non physiologic and inherently
unstable
Efficacy proportional to LVEF
Retrograde arterial flow … LVEF and cerebral perfusion, LVEDP !
Distal malperfusion …
The patient … sedate and non-ambulatory
Blood path and directional flow …
Aziz et al (2010) Initial experience with CentriMag extracorporal
membrane oxygenation for support of critically ill patients with
refractory cardiogenic shock JHLT 29:66
Determine blood flow requirements …
Neonate
Pediatric
Adult
100 to 150 mL/min/kg
75 to 120 mL/min/kg
50 to 80 mL/min/kg
Assumptions: “flow is laminar
viscous and incompressible …and the
flow is through a constant circular
cross-section …”
In reality:
Flow is rarely laminar …
Hct and temp affect viscosity …
The cross sectional area is a
composite of fixed (cannula) and
variable (vessels) components
…standardized system to
describe the pressure-flow
characteristics of a given
cannula … if specific flows are
needed to support a given
patient, an arterial and venous
cannula of an adequate Mnumber can be chosen from a
given nomogram that will support
flow at acceptable pressures
A single number that represents the
relationship between cannula size,
flow, and pressure drop.
M-number for tubing:
1/4 inch, 1 meter
M= 3.1
3/8 inch, 1 meter
M= 2.0
1/2 inch, 1 meter
M= 0.9
Assuming non-turbulent blood flow
 M-number :  resistance
Cannulation …
16F
18F
20F
22F
18F
20F
22F
24F
28F
(6.0mm)
(6.7mm)
(7.3mm)
(8.0mm)
(9.3mm)
55 cm (21.6”)
68 cm (26.8”)
(5.3mm)
(6.0m
(6.7mm)
(7.3mm)
Femoral VA ECMO … low EF
non-physiological: retrograde blood path with
limited pulmonary blood flow (oxygenator)
decreased LV pre-load … myocardial recovery
increased LVEDP … capillary leak
and acute lung injury
gas exchange … membrane oxygenator
cannulation … limb ischemia
This is not cardiopulmonary bypass … there
is no venous reservoir
Veno-arterial ECLS in cardiogenic shock
VA ECMO is not CPB …
any decrease in pre-load is at
the expense of increased
afterload
Left ventricular stasis …
elevated LVEDP with pulmonary
edema and LV thrombus
RV
Vent, apical cannulation,
septostomy, anticoagulation, or..
“hybrid procedure” … VA ECMO
and antegrade technology
Acute lung injury after mechanical circulatory
support implantation in patients on extracorporeal
life support: an unrecognized problem. Boulatea et
al (2013) European Journal of Cardio-Thoracic
Surgery 44: 544–550
Femoral VA ECMO … with myocardial
recovery
limited retrograde blood path with significant
pulmonary blood flow (oxygenator)
increased LV pre-load … myocardial recovery
decreased LVEDP … no lung injury
gas exchange … mixed …membrane oxygenator
and lungs
cannulation … lower limb ischemia
Management algorithms are complicated by inadequate
predictors of myocardial recovery … ECHO and markers
of perfusion
Mean arterial pressure
Veno-arterial ECLS targeted flow rates …
90
Cardiac power output > 0.6
80
70
60
50
CPO = MAP x CO/451
3.0
Cardiac output (L/min)
5.5
RIJ-subclavian VA ECMO
antegrade blood path with significant pulmonary
blood flow (oxygenator)
increased LV pre-load … myocardial recovery
decreased LVEDP …
8mm Dacron
gas exchange … mixed …membrane oxygenator
and lungs
cannulation … upper limb ischemia
RA
Subclavian Artery Cannulation for Venoarterial
Extracorporeal Membrane Oxygenation.
Javidfar, Jeffrey; Brodie, Daniel; Costa, Joseph; Miller,
Joanna; Jurrado, Julissa; LaVelle, Matthew; Newmark,
Alexis; Takayama, Hiroo; Sonett, Joshua; Bacchetta,
Matthew
ASAIO Journal. 58(5):494-498, September/October 2012.
DOI: 10.1097/MAT.0b013e318268ea15
RIJ dual lumen VV-subclavian Arterial
ECMO … hybrid ECMO (venoveno-arterial)
antegrade flow … mixed cardiopulmonary disease
“hybrid” VVA, or full VV, or full VA
support technology … not salvage
ambulatory
8mm Dacron
RA
Brodie and Bacchetta (2011) NEJM
…percutaneous approach
… trans-septal left ventricular
unloading
Evolving applications … “virtual VVA ECMO”
cor pulmonale and pulmonary veno-occlussive disease
68 yo scleroderma variant, elevated ANA…supra-systemic PA
pressures on continuous dobutamine, lasix qtt, high flow O2.
Failed vasodilator therapy x 3…non-ambulatory with progressive
syncopal episodes…
To cath lab…combined atrial septostomy and right IJ dual lumen
venovenous ECMO cannulation…bridge to transplant (ECMO day 4)
Cannulation …
Peripheral veno-arterial ECLS
RA/femoral vein…retrograde femoral a. (ECMO)
RA…antegrade right subclavian a. (8mm Dacron graft/ECMO)
LA/femoral trans-septal …retrograde femoral a.
Central veno-arterial ECLS
RA to pulmonary a. (right heart)
LA to aorta (VAD)
RA to aorta (ECMO)
(…application and
deployment)
Central cannulation …
Central cannulation …
PA
LA
… integrated MCS ECMO
cardiogenic shock …
femoral ECMO … to central ECMO …
to LVAD and oxyRVAD with RV
failure…
to long-term Centrimag RVAD support
… bridge to transplant
Cannulation and initiation … ten general rules and painful lessons
1. re-think “application” … why am I doing this and what do I hope to accomplish
2. re-think “deployment” … “this” cannulation strategy … “now?”
3. Got heparin ? (0.5 mg/kg) … plan an anticoagulation strategy
4. Crystalloid prime … or colloid prime (FFP)
5. Look at your lines … air, clamps, length, and entry points
6. Come up slowing … establish flow, then increase flow
7. Remember the patient … inotropes and airway (minute ventilation is 15L/min …
sweep is 10L ...!!!)
8. Most disasters happen five minutes after the celebration begins .. This is a human
endeavor
9. Any surgical bleeding is unacceptable
10. Have an exit strategy
… mortality assessment of preoperative risk factors that might
serve as targets for goal-directed
interventions meant to improve LVAD
candidate survival (age, albumin, renal
and hepatic insufficiency,
center experience)
Low risk < 1.58
Medium risk: 1.58 to 2.48
High risk > 2.48
Cowger et al (2013) Predicting Survival in Patients Receiving
Continuous Flow Left Ventricular Assist Devices:The
HeartMate II Risk Score. J Am Coll Cardiol. 61:313–21
“… preserved end-organ function,
however preoperatively achieved,
might be the most important
predictor of successful LVAD
outcome.”
bilirubin
lactate
RVAD
AST
ECMO
RVAD explant
Can pre-operative ECMO alter
the patient risk profile of LVAD implantation …
Or does it simply make the numbers better…
with the additional morbidity of a pre-implant
procedure?
LVAD
Na
Cr
Creatinine
ECLS
LVAD
The Right Ventricular Failure Risk Score (RVFRS):
A pre-operative tool for assessing the risk of right
ventricular failure in left ventricular assist device
candidates
Vasopressor requirement (4)
AST > 80 (2)
Bilirubin > 2 (2.5)
Cr > 2.3 (3)
AST
Low risk (OR 0.5)
survival)
High risk (OR 7.6)
survival)
RVFRS < 3 (90% six mo
RVFRS > 5.5 (66% six mo
Pre ECMO RVFRS score … 11.5
Post ECMO RVFRS score … 2.5
Bilirubin
Can pre-operative ECMO convert a patient
at high risk for biventricular support into a
“conventional” LVAD recipient?
Matthews at al (2008) JACC 51:2163
ECLS and cardiogenic shock…
Deployment of ECMO technologies in the context of
medical futility generally results in futile deployment of
technology…it is rarely “the device”
ECMO technology generally restores physiology but may
not alter survival depending upon the specifics of
deployment
ECMO can support patients awaiting good clinical
decision making … it is ineffective in supporting bad
clinical decisions