Role of ECMO in Acute Cardiogenic Shock Ezequiel J Molina, MD Attending Cardiac Surgeon Advanced Heart Failure and Transplant Program MedStar Heart and Vascular Institute – Washington Hospital Center Washington, DC I have no relevant financial relationships

Background Mortality rate of refractory cardiogenic shock is high Early initiation of MCS (ECMO) may improve outcomes Avoid progression of MSOF and optimize organ function Potential outcomes: Heart recovery Temporary or durable LVAD Heart transplantation Withdrawal of care and death

Ideal Support Device Easy and rapid implementation Provide robust hemodynamic support Biventricular support when needed Allow pulmonary support Cost effective Multidisciplinary team approach

Device Selection Patient status and location Etiology of cardiogenic shock Technology available at your institution Devices: VA ECMO CentriMag LVAD Impella Tandem Heart

VA ECMO

VA ECMO Abrams et al, J Am Coll Cardiol, 2014

ECMO Management MAP > 65 (minimize vasopressors) Adequate volume resuscitation Allow cardiac ejection and pulmonary flow Monitor for bleeding, thrombosis and sepsis Anticoagulation (ACT 160-200 sec) Monitor organ recovery Weaning strategies Multidisciplinary team approach

ECMO Advantages Allows for minimally invasive Rapid bedside application Biventricular support Pulmonary support Low initial cost Transport capabilities

ECMO Advantages

ECMO Disadvantages Labor intensive High cost with prolonged support Requires anticoagulation LV distension / thrombosis Historically high complication rates Limited duration of support

ECMO Disadvantages Burkhoff et al, J Am Coll Cardiol. 2015

LV Distension Inotropes Minimize vasoconstriction Central cannulation LV vent insertion Impella / Tandem Heart LVAD conversion

Device Comparisson Thiele et al, European Heart J. 2015

ELSO Survival Data

ECMO Outcomes AMI Negi et al, J Invasive Cardiol, 2016

ECMO Outcomes AMI Negi et al, J Invasive Cardiol, 2016

CentriMag LVAD Takayama et al, J Heart Lung Transplant, 2013

Conclusions Early and rapid recognition of cardiogenic shock Robust hemodynamic support may improve outcomes ECMO is our first line of therapy for cardiopulmonary support… before MSOF Bridge to bridge, recovery, transplantation or durable LVADs Survival to hospital discharge 20-40% Management guidelines are needed but difficult to develop Teamwork and communication at each stage is critical