ecmo cardiac surgery

Associate Professor of Medicine Director, Interventional Cardiology

Co-Director, Hans Hecht Cardiac Catheterization Laboratory University of Chicago Medical Center

Chicago, IL

Sandeep Nathan, MD, MSc, FACC, FSCAI

Extracorporeal Life Support

(ECLS) and Beyond:

New Directions in Percutaneous

Mechanical Circulatory Support

IABP Impella TandemHeart ECMO / ECLS

Impella 2.5 Impella CP Impella 5.0 Impella RP*

Percutaneous mechanical support options

* Investigational device

IABP Impella TandemHeart ECMO / ECLS

Impella 2.5 Impella CP Impella 5.0 Impella RP*

Percutaneous mechanical support options

V-V V-A

V-A-V

Extracorporeal Membrane Oxygenation

2 primary modes of ECMO:

• Veno-venous (V-V) ECMO primarily used for isolated

pulmonary failure

• Veno-arterial (V-A) ECMO used for cardiac or

combined cardiopulmonary failure

• A dialysis membrane may be added to the circuit for

renal replacement therapy

ECMO / ECLS

Central ECMO cannulation Peripheral ECMO cannulation

ECMO cannulation

Marasco SF, et al. Heart, Lung and Circulation 2008;17S:S41–S47.

V-V ECMO

V-V ECMO using 2 sites for

venous cannulation.

Cannulae are inserted into the internal

jugular vein (extending

into the right atrium) and the

femoral vein (extending into the inferior

vena cava

Single-site approach to V-V ECMO cannulation. A dual-lumen cannula is inserted into the IJ vein (extending through the RA and into the IVC). Venous blood is withdrawn through the drainage lumen with ports in both the SVC and IVC. Reinfusion of oxygenated blood occurs through the second lumen with a port situated in the RA.

Brodie D, et al. N Engl J Med 2011;365:1905-14.

Indications and contraindications

for V-V ECMO in ARDS

Brodie D, et al. N Engl J Med 2011;365:1905-14.

V-A ECMO

• Extracorporeal

circulatory support

device approved for

short-term (6 hrs LV

support, 30 hrs as an

RVAD)

• Magnetically-levitated

pump impeller

• Capable of delivering

high flows up to 9.9

LPM

Thoratec Centrimag

Maquet CardioHelp ECLS

CARDIOHELP HLS Module Advanced

Hardware Disposables Applications

CARDIOHELP System

Software

Transitioning to

Therapy

V-V Support/ Assist

V-A Support/ Assist

Maquet CardioHelp ECLS

• Smallest commercially available, pump and

integrated oxygenator (All in one heart-lung

support system)

• Biocompatible surface coatings for optimum

protection

• Extracorporeal Mechanical Circulatory Support

• Partial or complete cardiac output

• Support for CO2 removal and Oxygenation –

• 10 kg (22lbs)

• 14 x 10 x 17 inches

• Optional Sprinter Cart for in hospital mobility

Maquet CardioHelp ECLS

Integrated sensors for:

Venous pressure (P-ven)

Internal pressure (P-int)

Arterial pressure (P-art)

Arterial temperature (T-art)

Integrated cell for:

Venous oxygen saturation

Hemoglobin / Hematocrit

Venous temperature (T-ven)

HLS Module Advanced:

Maquet CardioHelp ECLS

Arterial cannulae (15-19 Fr) Venous cannulae (20-24 Fr)

Maquet CardioHelp ECLS

General range of flows achievable:

• 15 Fr arterial 3.5 – 4 L/min

• 17 Fr arterial 4 – 4.5 L/min

• 19 Fr arterial Up to 6 L/min

Data for adult ECMO

in cardiac failure

• N = 2,088 (total) • Indications: cardiac arrest, cardiogenic shock, shock with mixed

etiologies, post-cardiotomy shock, acute myocarditis, shock after cardiac transplant

• Series range in size from 5-219 patients, • Survival ranges from 0-91% Allen S, et al. J Intensive Care Med 26(1); 13-26.

Practical considerations

• Indications and contraindications • Mode of ECMO: V-V vs. V-A, vs. V-A-V • Timing & location of initiation • Availability of primary and provisional equipment • Type of system to be used • Vascular access • Timing of anticoagulation • Perfusionist support • Need for renal replacement therapy? • Aftercare, nursing instructions, securing of cannulae,

instructions regarding moving patient • Exit strategy???

Case study 1

67 year old man with ischemic cardiomyopathy (EF 25%) presents with progressive dyspnea, confusion, acute on chronic renal failure and refractory hypotension. Recent history of MI/cardiogenic shock requiring inotropic and balloon pump support, complicated by respiratory failure and ischemia/gangrene to right foot.

Other co-morbidities • Peripheral Arterial

Disease • Chronic Kidney

Disease • Multiple prior MIs • Recent DES implants • Paroxysmal AFib • History of prostate CA • Malnutrition

Hospital Course:

Refractory Cardiogenic Shock

• Started on Milrinone for inotropic support • Brief initial improvement, followed by progressive decline (increasing

lactate, decreased systemic perfusion, shock) • Pressors (dopamine, norephinephrine) initiated • Increasing frequency of tachyarrhythmias (atrial fib, NSVT) • Spiraling hemodynamics / progressive hypoperfusion / multi-organ

failure ensued despite extensive support with vasoactive medications

Key clinical considerations: • Progressive shock state • PAD precluding large-bore arterial access with ongoing R foot

ischemia following prior arterial cannulation • No residual ischemic/viable myocardium • Not a cardiac transplant candidate (for a variety of reasons)

IABP Placement:

Subclavian Approach

Raman et al. Ann Thorac Surg 2010;90:1032-4

• Given the extensive co-morbidities and clear need for additional hemodynamic support pending a decision on destination-LVAD therapy, the decision was made to proceed with a right subclavian IABP.

• This was performed without complications in the OR using a limited cut-down and synthetic graft anastomosed to the RSCA with fashioning of a hemostatic valve through which a Maquet 7.5 Fr. IABP was placed into the descending aorta

Hospital Course Continued:

Following IABP Placement

• Continued patient decompensation: • Increasing pressor requirement despite IABP • Worsening tachyarrythmias during which there was

no IABP augmentation • Worsening perfusion (increasing lactate, decreasing

SVO2) • Decision made to initiate percutaneous extracorporeal

life support [V-A ECLS (ECMO)] after extensive discussion between Interventional Cardiology, Cardiothoracic Surgery and Heart Failure / Transplant

ECMO Cannula Placement:

Femoral Approach with Antegrade Sheath

Antegrade 6 Fr Arrow sheath

in SFA for limb perfusion

15 Fr arterial cannula

(Medtronic BioMedicus)

21 Fr venous cannula

(Medtronic BioMedicus)

Extracorporeal life support (ECLS) was initiated in the

cardiac cath lab using the Maquet CardioHelp system

and peripherally placed cannulae.

Effect of Counterpulsation with

ECMO & IABP in Combination

IABP Console Maquet Cardiohelp ECLS Console

Decision was made to leave subclavian IABP in place for coronary perfusion and LV venting while circulatory / oxygenation support was provided by ECLS circuit.

IABP on Hold: Complete Loss of

Intrinsic Cardiac Pulsatility

IABP Console ICU Monitoring Screen

Hospital Course Continued:

Improvement on Combined Therapy

• Perfusion parameters begin improving with combination IABP and ECLS • Decreasing lactate • Improving renal function, urine output

without diuretic support • Vasoactive medications slowly able to be

weaned off • With increasing stability, patient able to receive

permanent LVAD (Thoratec HeartMate II) on post-ECLS day 3

Case study 2

39 yo female with severe pulmonary

HTN due to unrepaired ASD, s/p

cardiac arrest post-op (ASD repair,

DeVega TV ring) with refractory shock

ECLS initiation

ECLS initiated in cath lab:

• 15 Fr retrograde arterial cannula

(Medtronic BioMedicus)

• 23 Fr retrograde venous cannula

(Medtronic BioMedicus)

• 6 Fr antegrade sheath in SFA for limb

perfusion (Arrow)

ECLS initiation

Maquet CardioHelp ECLS

• Low cost of disposables

• Rapid cannulation (with ability to perform blind bedside procedures)

• Rate- and rhythm-independent support

• Pulmonary vs. cardiopulmonary support

ECLS in perspective

• No direct LV unloading – ideally need LV venting

• Possible cerebral / visceral hypoxemia with peripheral cannulation

• Modest support with 15 Fr arterial cannula

• Difficulty with securing of currently available cannulae

• Large-bore vascular access

PROS CONS

Near horizon for MCS

• Percutaneous

– Reitan Pump

– PHP

• Minimally invasive / Percutaneous

– NuPump

– Symphony

– Circulite

• The RCP is a 10 French collapsible percutaneous cardiovascular support device

• Positioned in the descending part of the thoracic aorta via the femoral artery.

Reitan Pump* – CardioBridge

* Investigational technology

The Reitan Catheter Pump System

CardioBridge – Mechanism of action

Acute on Chronic Study

Hemodynamics

Hemodynamics

Renal Function

Renal Function

Renal Function

Conclusions

Principles of Support

• Percutaneous insertion (10 F)

• High pumping capacity

• Afterload reduction

• Increased peripheral perfusion

• No crossing of aortic valve

• No ECG synchronisation

• Quick and easy setup

Device properties

• Propeller diameter 15 mm

• Diameter closed 10F (3.3 mm)

• Pump Speed up to 13,000 rpm

• Application time: approx. 7 days

• Minimal anticoagulation technology

Potential Areas of Application

• Heart failure

• High-risk PCI (need upper extremity access)

• Cardio-renal syndrome

• Pre-renal acute kidney injury (AKI)

• Pre- and post-open-heart surgery

Thoratec HeartMate PHP* (Percutaneous Heart Pump)

* Investigational technology

Impeller

Coated

Cannula

Cannula

Inlet

Cannula

Outlet

Insertion Sequence

Low-profile, rapid-insertion, catheter-based

percutaneous heart pump

Designed to provide high forward flow to

unload the LV and perfuse end organs

•Designed to deliver 4-5 lpm average

flow at 21k RPM

Collapsible elastomeric impeller and nitinol

cannula

Delivered through 12F sheath

Expands to 24F when unsheathed

Thoratec HeartMate PHP (Percutaneous Heart Pump)

HeartMate PHP Impeller Design

• CFD-aided design of PHP impeller blade optimizes hydrodynamic efficiency to allow for reduced pump RPMs

• Shear stress and hemolysis are potentially reduced

Initial design: 4LPM, 24Krpm, 60mmHg generated pressure head

Optimized design: 4.25LPM, 21Krpm, 62mmHg generated pressure head

+40%

HeartMate PHP Case Study (HR PCI)

0

0.5

1

1.5

2

2.5

3

3.5

4

Baseline On support Post-procedure

Cardiac index

0

20

40

60

80

100

120

Baseline On support Post-procedure

MAP

+70%

Time HR SBP DBP MAP CVP PAP PCWP CO CI

Baseline 80 92 54 70 4 21 13 4.42 2.15

On support

125 125 85 101 6 31 20 7.39 3.64

Post support

130 88 43 72 14 60 40 3.74 1.82

HeartMate PHP Development Timeline

2011 2012 2013 2014

Development & Testing

Major upcoming milestones 1. Initiate CE Mark study 2. Initiate US PMA pivotal study 3. Commercial launch OUS

EU Clinical

US Clinical

2015 2016

Abiomed SYMPHONY *

* Investigational technology

1 2

3 4

Abiomed SYMPHONY

Abiomed SYMPHONY

• Device output 3.0

L/min at 100 bpm

• Synchronized LV

unloading

GOALS of THERAPY:

• Increased coronary

perfuion

• Increased cardiac

output

• Reduced myocardial

O2 consumption

• Bleeding, bleeding, bleeding

• Vascular complications

• Cholesterol / air embolization

• CVA

• Sepsis

• Thrombocytopenia

• Hemolysis

• Groin / line infections

• Peripheral Neuropathy

Complications of mechanical support

• Graded approach to device choice / strategy should be based on:

• Extent of support required

• Duration of support anticipated

• Consideration use of hemodynamic support early in the treatment course and plan accordingly

• Cost considerations, anatomic/technical issues and cardio vs. cardiopulmonary failure issues factor in to decision

Summary

Thank you!