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Short-term MCS. When and how?
The document discusses short-term mechanical circulatory support devices like extracorporeal membrane oxygenation (ECMO) and the Impella pump. ECMO can be used to provide both cardiac and respiratory support through peripheral or central cannulation. It discusses indications, configurations, complications and management of ECMO. The Impella is an axial flow pump that is placed via catheter into the heart to unload the left ventricle and increase cardiac output, protecting the myocardium with less invasive placement compared to other devices.
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Short-term MCS. When and how?
- 1. Assistenze short term: bridge to recovery, bridge to decision, bridge to transplantation C. Amarelli Assistenze meccanicheal circolo: scelta, impianto e gestione.
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- 8. First successful ECMO patient, 1971 J Donald HillMD and Maury Bramson BME, Santa Barbara, Ca, 1971. (Courtesy of Robert Bartlett, MD)
- 10. Assistenze short-term • Cardiopulmonary bypass (CPB) •Complete cardiopulmonary support in the operating room • Extracorporeal membrane oxygenation (ECMO) • Partial cardiopulmonary support • Veno-arterial: cardiac and pulmonary support • No Blood-air interface • Lower Priming • Heparin-coated or low-thrombogenicity
- 11. Assistenze short-term ECMO physiology • Replaces/augmentsboth pulmonary and cardiac function • Perfusate mixes in the aorta with blood from left ventricle (arriving from compromised lungs); • O2/CO2 content = content of bloodreturning from the circuit + that of pulmonary source; • Systemic bloodflow = ECMO flow + patient’s own flow • EtCO2 – measures the return of native lung function
- 12. Assistenze short-term Indications: • Post-cardiotomy üwhen unable to get pt off cardiopulmonary bypass followingcardiac surgery • Post-heart transplant ü usually due to primary graft failure • Severe cardiac failure due to almost any other cause ü Decompensated cardiomyopathy ü Myocarditis ü Acute coronary syndrome with cardiogenic shock ü Profound cardiac depression due to drug overdose or sepsis
- 13. Assistenze short-term Several considerationsmustbe weighed: • Likelihood of organ recovery: only appropriate if disease process is reversible with therapy and rest on ECMO • Cardiac recovery: to either wait for further cardiac recovery to allow implant of device (LVAD) or to list for transplantation. • Disseminated malignancy • Advanced age • Known severe brain injury • Unwitnessed cardiac arrest or cardiac arrest of prolonged duration. • Technical contraindications to consider: aortic dissection or aortic incompetence
- 14. Assistenze short-term Veno-arterial (VA)configuration • Blood being drained from the venous system and returned to the arterial system. • Provides both cardiac and respiratory support. • Achieved by either peripheral or central cannulation
- 15. Central vs. Peripheral Cannulation Advantages – Flow from Central ECMO is directly from the outflow cannula into the aorta provides antegrade flow to the arch vessels, coronaries and the rest of the body –In contrast, the retrograde aortic flow provided by peripheral leads to mixing in the arch. Assistenze short-term
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- 19. Assistenze short-term Centralvs. PeripheralCannulation Advantagesfor Central Flow from Central ECMO is directly from the outflow cannula into the aorta provides antegrade flow to the arch vessels, coronaries and the rest of the body In contrast, the retrograde aortic flow provided by peripheral leads to mixing in the arch.
- 20. Assistenze short-term Disadvantages • Previouslyinsertion of central ECMO required leaving chest open to allow the cannulae to exit. • Increased the risk of bleedingand infection • Newer cannulae are designed to be tunneled through the subcostal abdominal wall allowingthe chest to be completelyclosed. • Central cannula are costly(approximately4times as much as peripheral) • Not safelyperformed bedside.
- 21. Things to Think About — Mechanical ventilation must be continued during ECMO support to try to maintain oxygen saturation of blood ejected from the left ventricle to at least above 90% in case of lung oedema. — ECMO flow can be very volume dependent —ECMO flow will drop: Ø Hypovolemia Ø Cannula malposition Ø Pneumothorax Ø Pericardial tamponade.
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- 23. Complications V-A ECMO critical Issues Bleeding and Thrombosis Aorticflow competitionà Pulmonary Oedema Left heart overload à Lower likelyhood of myocardial recovery Hypoxic coronary perfusion à Lower likelyhood of myocardial recovery Hypoxic cerebral perfusion/late implant à Neurologic sequelae (Time-dependent)
- 24. Complications of ECMO • Bleeding/Hemolysis – Out of proportion to the degree of coagulopathy and patient platelet count •Coagulopathy – Continuous activation of contact and fibrinolytic systems by the circuit – Consumption and dilution of factors within minutes of initiation of ECMO
- 25. Complications of ECMO • Thrombocytopenia – Platelets adhere to surface fibrinogen and are activated –Resultant platelet aggregation and clumping causes numbers to drop • Non-pulsatile perfusion to end organs – Kidneys – Splanchnic circulation seems to be particularly susceptible – GI bleeding, ulceration and perforation – Liver impairment
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- 29. Complications of ECMO • Mechanical Complications – Tubing rupture –Pump malfunction – Cannula related problems • Air embolism/Thromboembolism • Neurological: Intracerebral bleeds – Largely associated with sepsis • Manifest as seizures or brain death • Local complications: Leg ischemia – Particularly at peripheral insertion site of VA
- 30. Complications of ECMO Prevent Limb Ischemia • Separate arterial and venous cannulation • Non-occlusive cannulation of femoral vessels •Cannulation of Common femoral artery • If feasible without delay reperfusion use a T-graft to perfuse both proximally and distally • Monitor limb perfusion (NIRS) and upgrade to central ECMO or to limb reperfusion
- 31. CANNULATION TECHNIQUE • Open • Semi-open •Percutaneous Assistenze short-term
- 32. Assistenze short-term Femoral artery cannulation: • Chances of distal limb ischemia •Distal perfusion catheter is commonly used • Percutaneous reperfusion may be also performed Distal Leg Perfusion 7/9 Fr Cannula
- 33. Peripheral Femoral Cannulation– VA ECMO Assistenze short-term
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- 36. CANNULATION When doing centralECMO a Left atrial vent line can be utilized to monitor the LA pressure Assistenze short-term
- 37. Complications of ECMO Avoid Left Ventricular distension: • Lower flows warranting optimal sVO2 (>75%) measured on venous cannula (TIMING) •Reduce systemic afterload / mean pressure to leave aortic valve open • Inotropes • Check for pulsatility on arterial wave (aortic valve opening at Echo) • Check for good right drainage (less flow trough pulmonary artery)à if needed upgrade to central ECMO with left ventricular venting
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- 44. Management of Complications • Regular measurements of blood tests (Q6-Q8h) – Coagulation Profile –Platelet Count – Hemoglobin – Creatinine to evaluate for renal insufficiency • Aggressive replacement of clotting factors, electrolytes, PRBC
- 45. Weaning of ECMO – VA ECMO • Depends on cardiac recovery, Factors: –Increasing blood pressure – Return or increasing pulsatilityon the arterial pressure waveform – Falling pO2 by a right radial arterial line • indicating more blood is being pumped through the heart which may be less well oxygenated, – Falling central venous and/or pulmonary pressures. • It is important to note that cardiac outputs from pulmonary artery catheter are inaccurate on ECMO – Most of the circulating blood volume is bypassing the pulmonary circulation
- 46. Weaning of ECMO – VA ECMO Hemodynamically stablepatients underwent ECMO flow reduction trials to 1.5 L/min under clinical and Doppler echocardiography monitoring. When a patient had partially or fully recovered from severe cardiac dysfunction, tolerated the weaning trial, and had left ventricular ejection fraction (LVEF) [20–25% and aortic time–velocity integral (VTI)[10 cm under minimal ECMO support, device removal was considered.
- 47. Adult Heart Transplants Kaplan-Meier Survival by VAD usage (Transplants: January 1999 – June 2012) 0 20 40 60 80 100 0 12 3 4 5 6 7 8 9 10 11 12 Survival (%) Years Pulsatile flow (N=3,497) Continuous flow (N=2,856) ECMO (N=142) No LVAD / No Inotropes (N=10,271) No LVAD / Inotropes (N=10,606) All pair-wise comparisons with pulsatile flow and ECMO were significant at p < 0.05. No other pair-wise comparisons were significant at p < 0.05. 2014 JHLT. 2014Oct; 33(10): 996-1008
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- 55. TandemHeart: A better option for improving outcomes q Why TandemHeart? – Highest percutaneous flow –Direct Ventricle decompression/unloading – Cross-functional utility (Cardiology, C-T Surgery, ICU ) – Versatile configurations Ambulance Emergency Room Cath Lab or OR TandemHeart IABP/pressors Decision Recovery Surgery Dialysis Death Severe Heart Attack Bridge Risky Procedure w/ Low Survival Rate Transplant
- 56. TandemHeart: A VersatilePlatform Perc Right RA-PA (Fem) Perc Right w/ LVAD V-A ECMO V-V ECMO Surgical Left (Apex) Surgical Left (LA) Surgical Right (RA-PA) Surgical Left w/ Oxy Surgical Bi-VAD Perc Right RA-PA (IJ)
- 57. • A single platform and a full toolbox, with the right tool for each job. TandemHeart: AVersatile Platform The percutaneous ventricular assist device in severe refractory cardiogenic shock. Kar, et al. J Am Coll Cardiol. 2011 Feb 8;57(6):688-96.
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- 59. TandemHeart vs. LV-Axial Support • TandemHeart operates at 90 mmHg pressure, similar to a healthy native heart • All LV-axial devices operate at lower pressures (60 mmHg) •Performance is defined by a combination of pressure and flow • Power Output combines pressure and flow performance into a single measurement ∆ Pressure (mmHg) Flow (L/min) Power (Watts) Healthy Left Ventricle 90 5.0 1.00 TandemHeart @ 7,500 rpm 90 4.4 0.88 21 Fr Axial @ P9 60 4.4 0.59 14 Fr Axial @ P8 60 3.3 0.44 12 Fr Axial @ P8 60 2.1 0.28 1.00 0.880.59 0.44 0.28 1.0 2.0 3.0 4.0 5.0 6.0 50 60 70 80 90 100 Average Flow (L/min) Average ∆ Pressure (mmHg) Power Output (Watts) Healthy Left Ventricle TandemHeart @ 7,500 rpm 21 Fr Axial @ P9 14 Fr Axial @ P8 12 Fr Axial @ P8
- 61. IMPELLA è unamicropompa assiale intravascolare a supporto del sistema circolatorio del paziente La rotazione dell’IMPELLA produce una pressione negativa che aspira il sangue attraverso l’area di inflow e lo pompa in aorta ascendente attraverso l’area di outflow bypassando la valvola aortica Il flusso generato è proporzionale alla velocità di rotazione gestita attraverso la console TECNOLOGIA IMPELLA
- 62. * Assistenza Cardiaca idealePiattaforma Impella Sicurezza, Facilità d’uso Supporto Emodinamico Sistemico Protezione del Miocardio • Ripristina o aumenta la gittata cardiaca netta • Riduce la richiesta di O2 • Aumenta la disponibilità di O2 • La più piccola pompa cardiaca del mondo • Indipendente dal ritmo cardiaco e dai farmaci inotropi PRINCIPI DELLA PIATTAFORMA IMPELLA
- 63. Potenza Gittata Cardiaca EDV, EDPPAM Flusso Protezione Miocardica Supporto Emodinamico Inflow (ventricolo) Outflow (radice aortica) Lavoro meccanico Tensione parietale Resistenza microvascolare Flusso Coronarico RISULTATI FISIOLOGICI DEL SUPPORTO IMPELLA Richiesta di O2 Richiesta di O2
- 64. IMPELLA: FAMIGLIA DI PRODOTTI IMPELLA 2.5 IMPELLA 5.0 IMPELLA LD Flow Rate (L/min)2.5 5.0 5.0 Circulatory Support Partial High-Flow High-Flow Catheter Size 9 Fr 9 Fr 9 Fr Pump Size 12 Fr 21 Fr 21 Fr Insertion Method Percutaneous via Introducer Sheath Peripheral via Arterial Cut-down Direct Surgical Insertion Guidewire thickness 0,018” 0,025” N/A Cannula Geometry Curved/Pigtail Curved/Pigtail Straight Micro-axial Pumps L’ Impella® 2.5 è indicata per l’uso clinico in cardiologia e cardiochirurgia fino a 5 giorni L’ Impella® 5.0 è indicata per l’uso clinico in cardiologia e cardiochirurgia fino a 10 giorni
- 65. Cardiac Power Output EstimatedIn-HospitalMortality(%) ImpellaincreasesCPO (Seyfarth) Systemic Hemodynamic Support In AMI Cardiogenic Shock … Fincke et al. (2004) Impella devices DO NOT have specific labeling for AMI Cardiogenic Shock. See Slides 1 & 2 for specific Indications for Use of Impella 2.5 and Impella 5.0, LD CPO = CO x MAP x 0,0022 (watt)
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- 67. Impella Recover ®Microaxial-VADs Recover LD & RD = thoracic; LP = transfemoral Recover®LP 5.0 Recover®LD Recover®LP 2.5 Recover®RD Impella: Differentsolution for every setting
- 68. Comparison of RV Support Alternatives CentriMag Impella RP TandemHeart Effective and safeHDE HDE 510(k), 500 patients Easy to implant and explant Surgical, OR Implant OR Explant Groin, Rigid, Perc/CCL IJ/Neck, Flexible, Perc/CCL Easy to transport Stable, but Pump off patient Pump in patient, but groin limits Away from groin, Ambulatory pump Easy to care for Open chest, Surgical cannulae Groin Away from groin, Ambulatory pump Economical Cheapest system, Add'l OR cost, Add'l ICU cost Expensive Less than Impella, Lower explant/ICU cost vs. Centrimag (patient consent & IRB required)
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- 80. Assistenze short-term Conclusioni • L’assistenzameccanica di breve termine necessita di una organizzazione logistica e di competenze che permettano l’impianto anche al lettodel paziente. • Non appena raggiunta la stabilità e ripristinata la funzione degli organi è cruciale la pianificazione dello step successivo (impianto LVAD long-term, correzione chirurgica, trapianto di cuore o polmone). • La mortalità della assistenza meccanica del circolo dipende in maniera diretta dal timing con cui il sistema è stato impiantato e dalla rapiditàcon cui è stata ripristinata la funzione d’organo.
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- 82. Thank you foryour time.
- 83. “The use ofstatistics in medical research has been compared to a religion: it has its high priests (statisticians), supplicants (journal editors and researchers), and orthodoxy (for example, p<.05 is “significant”)” Benjamin Freedman Alternatives to RCTs should be considered: • when therapies are potentially life-saving • when the technologies are developing rapidly • when RCTs are not the most efficient method • when non-randomized data is compelling Healer versus Investigator The Fundamental Conflict