Optimal Therapies for End-Stage Thoracic Organ Failure: The Critical Role of the Surgeon and the Use of ECMO, MCS and Transplantation Decision Making:

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Presentation transcript:

Optimal Therapies for End-Stage Thoracic Organ Failure: The Critical Role of the Surgeon and the Use of ECMO, MCS and Transplantation Decision Making: ECLS - Bridge to VAD, Transplant, Recovery or Oblivion Evgenij V. Potapov, MD, PhD, Felix Hennig, MD and MCS Team of DHZB, Berlin, Germany

Definitions Allways emergency Indications ExtraCorporeal Membrane Oxygenation ECMO is a temporary support of heart and/or lungs with the goal of recovery or bridge to definitive solution Modern terminology: ECLS (ExtraCorporeal Life Support) Allways emergency Indications Acute heart and/or lung failure with high mortality rate ARDS (pneumonia, post-trauma) Cardiogenic shock (post cardiotomy, aMI, intoxication, acute myocarditis….) Post HTx or post LTx Warming up after hypothermia DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

Implantation OR, cath lab, bedside General or local anesthesia Placement Central (sternotomy, left lateral thoracotomy) Peripheral (a. axillaris, a. femoralis) Open with or without graft or per punctionem Ensure adequate extremity perfusion DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015 3

Open Access with Distal Leg Perfusion DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015 4

Percutaneous Cannulation DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015 5

LV Distension Reason – myocardial dysfunction and increased overload through ECLS flow Increased LVEDD, LVEDP and wall tension may preclude myocardial recovery Increased LVEDP may lead to pulmonary edema and irreversible loss of lung function DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015 6

Vent Alternativs - fast and less invasive Inotrops, IABP, atrial septostomy Directly through left atrium LV apex Transaortic with pigtail catheter (Fumagalli R et al., Int J Artif Organs 2004) Transseptal access (Aiyagari RM et al., Crit Care Med 2006) A. pulmonalis 15F cannula (Avalli L et al., ASAIO J 2011) A. pulmonalis with Smartcannula® (von Segesser LK et al., Thorac Cardiovasc Surg 2008) Impella DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015 7

v-a ECLS – Clinical Considerations Aortic regurgitation Central hypoxia due to lung failure and preserved LV ejection BGA / pulsoxymetry right arm or head Stop inotropes, venting Distal leg perfusion 8 Fr. ArrowFlex introducer LV Distension Inotrops, Rashkind, Venting Weaning Flow reduction, no gas flow reduction Gaffney AM, BMJ. 2010; 341; 982-986 DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015 8

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB v-a ECMO Algorithm 11

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

Number of PubMed Publications on “ECMO” DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

Crucial Questions about Further Treatment When to implant - -window of opportunity What to implant – HTx, LVAD or BVAD Whom to implant When should we step back DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

In “chronic” heart failure, ECLS represents a bridge to VAD or HTx whereas in “acute” settings it offers a considerable chance of recovery, and is often the only required therapy. DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

Weaning Recovery of the lung function Myocardial recovery Weeks Improved compliance, X-ray and BGA during similar ECLS setting SaO2 > 90% under 2 l/min flow  weaning trial Myocardial recovery Pulsatility, LV ejection Decrease of inotropes and vasopressors Most likely between 2nd and 5th days of support (Smedira et al. J Thorac Cardiovasc Surg 2001) No weaning if LV-EF < 30% after 2 days (Fiser et al. Ann Thorac Surg 2001) Weaning under ECHO control and almost free from inotropes DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015 28

Stable on ECLS, Weaning Not Possible – What to do? Decision should be made during first 5-7 days Is the patient HTx candidate? – consider waiting time on ECLS VAD implantation on ECLS is a high-risk surgery VAD should be considered if Organ function may be compromised, but showing improvment Neurological check-up is essential, CT if required Lung function - on ECLS is difficult to access Renal function - dialysis does not preclude VAD Liver function - bilirubin < 10 mg/dl or decreasing Mostly no switch to CPB is nessesary, implant on ECLS Mostly LVAD + temporary RVAD ± oxygenator DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

TandemHeart RA-PA Cannula (RVAD) - No re-circulation - No cannula at the legs

DHZB ECMO / ECLS Experience 2014 149 adults (+ 25 children) 103 male vs. 46 female v-a ECMO in 125 patients v-v ECMO in 24 patients Peripheral cannulation 104 patients central cannulation 45 patients DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

DHZB ECMO / ECLS Experience 2014 aMI 15 patients cardiogenic shock 34 patients post Tx 15 patients post cardiotomy 85 patients switch to LVAD 19 patients (after median 6 days, range 3-20 days) weaned 17 patients (after median 12 days, range 4-47days) expired 107 patients DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

ECMO / ECLS as Bridge to VAD Data of patients who underwent ECMO / ECLS prior to VAD implantation between 01/2013 and 10/2014 were analyzed retrospectively. 22 patients 15 male, 7 female 12 dilative cardiomyopathy 4 ischemic cardiomyopathy 4 myocarditis 2 acute myocardial infarction In 10 patients CPR was necessary at least once before VAD DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

ECMO / ECLS as Bridge to VAD The femoral artery and vein were accessed in all but one case. Antegrade leg perfusion was established in 20 patients. Median time on ECLS was 4 days (range 1-31 days). 30-day mortality after VAD implantation was 45%. Six patients survived to hospital discharge. No differences in clinical parameters were noted between survivors and non-survivors. DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

ECMO / ECLS as Bridge to VAD Patients receiving long-term ventricular assist devices (VADs) for refractory cardiogenic shock (rCS) with multi-organ failure present substantial postoperative mortality and morbidity. Conditioning these patients preoperatively with extracorporeal life support (ECLS) could offer an improved outcome. DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

Conclusions For treatment of severe cardiogenic shock with unclear neurological status and/or MOF, ECLS is a valid initial option Survival remains between 25 and 50% Institutional SOP, mobile team and regular training are crucial Leg perfusion reduces leg ischemia and concomitant morbid complications In decompensated acute heart failure (e.g. myocarditis, Takotsubo, AMI, acute poisoning) weaning is an option In decompensated chronic heart failure (e.g. DCMP or ICMP) subsequent VAD implantation is the only option DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015

Conclusion After stabilization and conditioning on ECLS, VAD implantation can be performed, yielding improved outcome as compared to primary VAD implantation Decision about VAD implantation should be done within first 5-7 days of support In case of switch to VAD, mostly LVAD + temporary RVAD configuration is necessary Preceding CPR or prolonged duration of ECLS does not preclude successful VAD implantation DHZB | Optimal Therapies for End-Stage Thoracic Organ Failure | Seattle 25.04.2015