Demtris Yannopoulos of the University of Minnesota elaborates on the evolution of cardiac resuscitation. He discusses coronary artery disease in patients with out of hospital refractory ventricular fibrillation cardiac arrest, early ECMO facilitated resuscitation, and more. This CME also includes surgical and radiation clips.
Related Links: Twitter @PennMDForum Yeah. Okay. All right. Good morning, everybody. Welcome to Penn Cardiology Grand Rounds Today. CMI code is 70671 and we'll make sure that's in the chat box as well. Similar to prior grand rounds. Feel free to leave any questions or comments in the Q and A tab or the chat box. I'll be monitored during those, and then we'll leave the last 10 minutes or so for a Q and A session at the end of the talk. I just want to point out a couple of other Penn Medicine based CMI, Um, events that are upcoming. One is heart failure, with preserved ejection fraction and the other one being session to on the mitral valve and mitral regurgitation, this one focusing on functional mitral regurgitation. Again, the code for today is 70671 All right, well, it's a couple minutes after 7 30 So let's get started here Today. We have Dr Dimitri Yannopoulos from the University of Minnesota. Dmitry received his medical degree from the University of Athens and Greece. He then did his cardiology training at the University of Minnesota and interventional trading at Johns Hopkins. He serves as the medical director for the center of Resuscitation Medicine at University of Minnesota and is now the chair of the New Horizons and CPR at the American Heart Association. Dmitry has several aro one grants to study out of hospital cardiac arrest in the use of ECMO and early access to the cath lab for these patients. Wow. As most of you know, we have a mobile VV ECMO program here with Dr Zito and the Pen Cardiology Shock Team. And that's being expanded to via ECMO. And Dr Yannopoulos is an expert in this area of out of hospital arrest as well as mobile ECMO. He's really a leader in this area, and we're very honored to have him speak to us. And we're very excited to learn about his experience and what they've learned in Minnesota. So, Dmitri, welcome virtually to Penn Cardiology grand round. I'm gonna stop my screen sharing and I'll let you take over. Good morning. Thank you so much for the invitation. Thank you, everybody. Um, I'm just trying to make this a little bit. Can you see the screen? Okay. Yep. Looks good. Okay, Very good. Let me just take all this thing away here. Mm. Okay. So, um, good morning. And it's, uh, in order to be invited to talk to your institution. I have, um, the intention to talk about the evolution of cardiac resuscitation kind of medical management and involvement of, uh, our new technologies in the management of these very sick patients with very green prognosis in general. Um, these are my disclosures. I don't have any significant financial issues that I have to report other than have received funding from an age and Department of Defense and the Helmsley Charitable Trust in relation to my work. Characteristic epidemiology is not unknown to most cardiologists. Correct surgery. Uh, folks, also, emergency physicians in the majority of, uh, hospital based, uh, specialties in medicine. About 600,000 people with cardiac arrest every year. About 400 of those are out of the hostel. Cardiac arrests. And as you all know, this is the third leading cause of death in United States. Outcomes have been pretty flat over the last few years, with about 60 to 80% of survival is presenting with sharp double rhythm, despite the fact that it's only a quarter or a third of the presenting rhythms. Um, and, um, the management of it has been pretty stagnant over the last 50 60 years. Were the idea of, um, compressions and defibrillation. Start involving, um, and took, uh, you know, the streets with a B. L s and a CLS. What we have seen is that the focus on systematically restructuring of responses have led to an earlier identification of people with characteristic spots related CPR efforts, a public training to do bystander CPR. And you know, a lot of training with paramedics to do better quality of CPR upon arrival and then the issue of transferring transferring patients to the hospital and the A. C. L s in ICU and Catholic roles have been difficult to define. And I'm going to try to make an effort to define those things for you and the importance that highly skilled centers and physicians and teams may have in the future of, uh, fighting this disease. Um, just setting data for you here about five years worth of data. Six years worth of data Minnesota from, uh, 16 13,007 and a half 1000 cardiac arrest. 2400 have been BF arrests, and you see here in its point, um, how many people die immediately don't have passes with all the rhythms and then eventually About 84% of the 773 out of 923 patients survived with biological function where, um, initially presented with stackable rhythms. So we have a higher survival related to we have here than nationally. Um, and it is possible to be the difference to be the way they present or reported data find the F might be missed many times and not be reported correctly. But I think a very important aspect of all this is the understanding of how time sensitive characteristics and the more we have studied, the more we realize the importance of time. No, these three slides here, upper left, is people that are resting for of paramedics. So the best case scenario is here where you see the survival based on the T V, the T V f, the dark line P A and a sisterly as a function of time. And this is the best case scenario, with medics being in front of the patient when we arrest from the North. American data from the rock trials, and you realize that about 30 minutes to 40 minutes you have reached single center single digit outcomes in Korea. In the upper right, you also see the very steep decline between 10 minutes of CPR and 30 minutes of CPR, reaching almost zero survival within that time, the largest cohort of data showing this effect of time. It has come from Japan, where they have national registries, and you see the dark line here on the bottom, being the probability of survival as a function of time and you see very green progress is in the best case scenario with soccer ball. People talk about rhythm, presenting with a bystander CPR, reaching almost zero at 40 minutes. And, uh, the conclusion for all this is that standards and station strategists are inefficient as the duration of CPR increases. Survival is going after 30 minutes of CPR, even in patients with initial shock algorithms, um, with standard of care. And the question is that we started questioning is as we were doing these cases in 2012, I started taking some people in the catalog with ongoing CPR. I started having interesting with the station science since I was in India in 2000 in I was curious why some people VF Ah, you have the ability to have returned spontaneous circulations and others do not. We figure out after about 12 14 patients that there is a high prevalence of coronary artery disease. So then the question became to my mind before I started changing clinical protocols to see if initiating ECMO in this refractory patients is a means to be able to overcome the significant coronary artery disease burden and jump start the heart easier than trying to do PCs with ongoing CPR and see what happens and support the heart. So we did the first randomized alien animals where we randomised animals with ischemic VF lady occlusion CPR for 10 b a lesson. Then we did F p versus No M P A. C L s for 35 minutes, and then it was a two by two study, and then we basically, uh, open the arteries up like I would do somebody in the cath lab without going CPR and then try to see if the animal would be able to resuscitate. Let's put the animal on the neck machine, open the heart up and then see the can resuscitate. And it was a very interesting study because two things happen. Um, Ackman Survival obviously was almost universal. And Pena, from despite increasing systolic and diastolic and coronary perfusion pressures, did not really improve. Survival was associated gently with this lower survival rate. And here on the red, you can see animals that received ECMO was significantly higher than animals that did not, and epinephrine actually did not have an effect. Um, as you can see here, the red epinephrine with ECMO versus negative epinephrine on the bottom had significant difference as well. But it's interesting to to see for the first time that one of the reasons these animals could not come back was the metabolic profile they had was so abysmal that the heart could not really restart, especially given the fact that he had a very large area of ischemia present. While all this is happening So subsequently, we developed in 2000 and of 2014 the University of Minnesota, a CPR protocol. We basically included ages 18 to 75. People were presenting soccer ball rhythm and patients that they failed three shocks initially, and they had to have the ability very happy to incorporating Lucas device and estimated transport time to from the scene to Catholic with less than 30 minutes. Obviously, exclusions are standard. The United Deny mercy home residents and clear non Catholic theology. We're effectively initially excluded from all these things, and the political is simple and has stayed through for the last six years. And part of the Aristotle. We used, uh, the profusion criteria as defined by the lactic acid and p 02 and Intel C two upon arrival to make decisions. To calculate or not, we didn't want to calculate people that have been far gone. Um, and I'll show you with the video of the calculation strategies. So we presented in region in the 1st 27 patients, and so at about a 40% survival there, and then subsequently the idea of, uh, the the theology of the factory kind of caressed came to life were realized more and more that people must have a reason that they do not come back. All of this idea came from the initial group of 12 14 patients that I did with ongoing CPR. So what? This protocol, um, did is that people with In fact, we have a rest. We're basically transported after three shocks to directly to the cath lab where easy Unless we appreciated, uh, extremely fast. And an angiogram lpc, Iowa needed was performed and admitted to the hospital compared that to historical cohort of patients that were treated from the same M s systems with the same age population. And also no, we couldn't count the shocks, obviously. So we had to use, um in order as a surrogate of refractory nous. And in that case, patients had to have to ask before they admitted to the hospital versus uh, they could be declared dead before risk admission. Ruskin Admission. So what we found was quite profound because this has stayed through over the last six years. Even after this paper that about 70% to 85% of our patients you have significant coronary artery disease. The final more than 70% lesions and what is interesting is about again. More than two thirds of these people have two or three vessel disease led is predominantly the vessel, but left men is very early the vessel, and they have moderate to high cinta syntax course. Um, about 62 3rd of the people have an acute robotic collision, and about a third of them have concomitant chronic total occlusion, which effectively, what we see very commonly, Um, when ischemia is, the reason for the arrest is that you have a chronic lesion and then a secondary, uh, event, usually an led occlusion or another from mark event that puts the people to refractory V F. The data was kind of shown to be true. Um, also in Paris, where they saw a similar distribution about 70% 75% involvement of coronary artery disease. Again, they show here really being the predominant vessel and equal distribution of vessels in the right and the coronary in the left circle flex. The historical comparison between the two groups showed that despite the fact of starting over 100% of the patients out in the field, we have very few people here. About 8 10% have pulses within cohort with that cohort to we are presenting, uh, and despite very few people achieving Rusk, we admit about 75% of these people initially because we don't need pulses anymore to admit somebody We just need to have ECMO that initiate initiates risk effectively and eventually the cardiac function recovers at least the electrical activity of it. This and the It's like contradistinction with a control group where you have to have policies in the men's department and you have to sustain your own life in order to be admitted. So there is an attrition of patients. Call from the field to be admitted in the men's department because Rusk is needed, admitted to the hospital and hospital this chance. So what we did effectively is we took the patients and we eliminated the need for risk in order to be admitted. But they had to have some perfusion criteria. And then you see the attrition, significant attrition of patients dying within at the hospital and usually within the first four or five days, and then we have survival. So we ended up having 26 survivals out of 60 62 26 survivors of the 170. So, in a way, the way I suggest people to think about it, you know, we're not magicians were trying to do things that you know, one battle at a time in order to win the war, you have to overcome the obstacle of returns. Potential circulation have to bring somebody back as soon as possible. Then if that happens, a lot of people already arrest as well. And you have to, you know, be able to show that you can overcome that obstacle and obviously the Holy Grail of characters station the ability to protect the brain from recovery. And, you know, again, this is something that has very little progress over the last few years and very little understanding of the brain. Very complicated structure. But echo does this, so oh, you take away the obstacles that eliminate the possibility of people to actually materialized neurological recovery. And so, um, you know, it's a It's a paradigm shift of how you manage this. And now I'm going to talk a little bit about the effect of time, um, on outcomes with the CPR. And we compare the 161st patients of the CPR in Minnesota with the outs cohort and the other online booking placebo trial from NIH. And we identified 650 patients. I had the same criteria, um, 18 to 75 3 shocks. Uh, another given, and we had the data that duration of CPR associated with their outcomes and its profound here to see that in orange. This is the best CMS systems in the United States, and if you receive CPR for you know, 1st 10 minutes and get passes within that period, you have about 60% survival rate. It drops about 15 to 25%. Subsequently, from 20 to 30 goes to 50 to 25 in the majority of the people that survive really come from this first half an hour, although there were about 300 plus patients that received CPR regulation from more than 40 minutes, not a single soul survived with these efforts, and I'm kind of distinction I can show you here a group of our patients where patients that very few that received CPR within half an hour from the arrest 100% survivals and then every 10 minutes after that. As the duration of CPR increases, there is a drop of about 25% in survival, reaching a plateau of about 15 to 25% as time goes by. And this is actually something we have seen recently. It's just, um, Asterix and all this because of covid, we see delayed home presentations, and our survivor has dropped about 25% of the last four months where we haven't seen a single public arrest. Most of people arrested home, and we cannot get to them earlier than an hour, which is kind of, you know, comes with the time. But, um, we don't have to be a statisticians to realize the difference between those two groups here, especially in this area where it's, uh, no survival in these groups. But in the paper, uh, you know, when we adjusted the model for superior duration, there was almost a 40 odd ratio in favor of ECMO. Why do these people die? The truth is, you know, the old idea about the three regions of death for cardiac arrest does not apply for ECMO. We every single song with rare exceptions, die from neurological injury and which is a good and a bad thing we don't. Most of these people present late as you see the later you present, the more brain death defying as brain oedema in the inner city, and then obviously absence of reflexes. Um, as time goes by. Also, um, we have people that fail resuscitation, meaning that they present with metabolic factors that they are unfavorable to be calculated in. They are dead in the Catholic because, you know, we cannot resuscitate the heart. So the later you present, very few people get admitted that will have any other reason to die from other causes. And so the majority of these people die because either they were too sick to be calculated or they basically dying the Catholic or they had brain death. In a very, very small proportion of people, they will be discharged alive with unfavorable function, which is no different than any early patients that I have in the hospital without ECMO, Um, and survived in neurological injury. Most of this injury depends on the, uh, very hospital characters of these patients, especially in the absence of, um, um of bison recipe. Our our witness states, this is the first detailed car metabolic profile as a function of time that we are aware of, uh, in this population of back more, and you see upper right here, lactic acid being the market of body, uh, lack of oxygen supply. You see that about minute 40 to 50. There is a significant jump from sub 10 to above 10. And this is when you know the outcomes changed dramatically. PH also represent the same metabolic changes. So because I mean the metric biologist, I kind of feel that there is a significant lack of interest that has, uh, being available in the United States about the role of the Catholic. But I kind of believe that VF VT have are part of the continuum of acute coronary syndromes. And unless we see that way, we won't be able to make, uh, forward strides. Not every VF is because of coronary artery disease, Um, but the most extreme time sensitive emergencies, as I showed you. But there is a big component of what, uh, the causes are related to the coronary artery disease status of these patients, not necessarily acute events. Chronic events can be the reason for that. So the involvement of cardiology any domestic ideology, I think is paramount. In order for this field to move forward and lack of the skills and expertise of cardiologists and involvement to understand this patient population will be an obstacle in the change of care that is needed. So if you look at people that have the FRS, there are three categories people that get pulses in the field, the people that don't. If the people get pulses and they have S t elevation, then he can see that there is a very high burden from 70 to 95% of coronary artery disease in about three Out of, uh, three or four out of five of these patients do have acute lesions, and in fixing, they don't have EST elevation. Obviously, the probability of coronary disease less and these people tend to do better. But one you're going to miss one in four or one in three patients. Significant lesions because the kids is not always, uh, able to show this post is a station. When you have refractory V X, though, it's extremely high probability of coronary artery disease in the same range with S T elevation presentation. And, uh, remember why I suggested this in? Um, obviously we'll see how it shows. It's in this paper that this is ambulatory patients ambulatory presented with just paying the merged departments in the probability of coronary artery disease and survival rate. Blue is the probability of survival. 40 50 80. Uh, 90. Sorry, sorry. Probability of survival is the orientation. The probability of coronary artery disease is the blue, um, with increasing by a stable angina and non stimulants to me. And obviously the mortality is very low. About 5% of the United States for people with s to me, 4 to 5%. And if you look at the blue bars, you can see that in people with presenting with 50 and knows that means them in refractory. The probability of coronary artery disease is the same as a non stemming population as the unstable and non stemming population. And if there is a standing in VF the probability of coronary artery disease even higher than the ambulatory patients with stemming and if you look at the refractory were population is very similar to the stemming populations. So there is a big component that involves coronary artery disease and comes towards our field here. Obviously, the mortality rate because of the is almost half. Um, and, uh, you know, this is the CPR programs that they are, uh, experience versus the national average. That refractory we have been read. No, we have. This is unpublished data. So it's our own institution data. Whether you show we show about 1000 patients that they have, uh out of the horse and carriage caressed, divided by it's a state of the hostel characteristic refractory of the host a characteristic. And we compare those people with access patients that they had stemming and non stem me as far as mortality and survival drops significantly as you go from left, right as you expect, and then we present here the probability of it's a probability of presentation as a function of the Johnson score being, uh similar to syntax. Score a score of severity of coronary artery disease, and you see that most of the people with simple disease tend to have lower distance course and then asked Incident score increase above 200. The predominant presentation is refractory ischemic carrick arrest in this population, and that tells you that these are people that present with very early. The first presentation of these people is correct arrest most of the time, very few people present with history of chest pains, and they do sometimes, but very few, um, the outcomes are very important to remember are related to the ability to operate in the critical care environment, that it's one of the most demanding in these populations. They have all these other issues besides correct dysfunction. The correct problem really is the list of of the warriors of these patients. Most of these hearts recover, Um, and it's not a limiting factor, But all the other things are what will kill them if you don't aggressively treat them. A good paper for this review would be my partner's suggestion. Bartos, who is a critical care in the West archaeologist and has described this tingling detail as a shortly here. You can see what you expect for this basic population. Most of the people are the candidate within 5 to 7 days, and they're following commands. The survivors, you know, up to 20 days before they can actually follow commands are excavated, uh, a little bit after in the hospital discharge all the way up to 30 40 days, meaning that this is a very long duration of stay with ICU involvement and resources heavy in order to have a successful program. Now, because no matter what we did, you know it was very difficult for people to, um eliminate the possibility of selection bias. Although, you know, I yelled all the way to the top of my screams as my lungs speak that there is no way I can select have a selection bias with paramedics bringing me anyone to the cath lab had no say over it. But again, we had to do a phase two trial here because there was at least a theoretical equipoise in this process. The arrest trial was a randomized face to single center multiple VMS Intention to treat was performing in the greater Metropolitan area was founded by men. Shelby I, um, under the majesty, circumstances and exceptions from consent. Obviously, uh, we had an i. D from the FDA, supervised by the F d A. Approved by the air B and monitored by an independent. And it should be i data safety monitoring board. The same criteria I told you earlier as a clinical practice were implemented for the trial 18 to 75. BF three shocks Lucas in less than 30 minutes of transport time. Once a decision to transport has been made. Exclusion criteria standard. Once people arrive, the men's department they were randomized to either get an ECMO facilitated station or standard CLS very quickly. If you are randomized to act more, you go to the Catholic. You bypass tumors department if you have no risk, which is the majority of the cases, Um, upon arrival or in the cath lab, if you don't have pulses, we get a blood gas. We looked at Intel CEO to if you do have a P 02 of less than 50 or lactate more than 18 and entitles you to less than 10. Uh, you do not proceed. Your declared death. If you have one of those, are none of those. You go a neck more and then you admitted to the hospital. If you present with Ross, we treat you with the manager Graham PC I. If you're in shock, you can have any mechanical assist devices available. Um, act more included and then go down the path. And so it's an intention to trial. And if you don't have you don't know much with the standard is your list. You have to have at least another 15 minutes of CPR in the men's department, or at least a total of 60 minutes from 911 call, which is far more than any any patient received less in any state. Um, nowadays, if you had pulses though, or achieved pulses in the emergency department, you went to the cath lab. And if you just needed echo support by either re arresting or cardiogenic shock, you will be placed on mechanical support, the outcomes for survival to hospital discharge and obviously favourable neurological outcomes three and six months. I'm not going to bore you the statistical design. You can read it on the paper if you want to. But effectively, we power the study to have, uh, 37% survival for ECMO versus 12 1 a CLS. And, um, if the hypothesis was true, we will have randomized 77 patients 52 in the act 1 25 in the A C. L s. Um, and we had an early stopping criteria with, uh, posterior probability in favor of either and being more than 98.6%. The D S and B was obligated to provide a formal recommendation on whether to stop the trial or not. Um, the trials started in Northern just 8, 2019 and terminated 10 months later, after 30 patients were randomised because we we went higher than the pre specified miracle stopping criteria. 36 patients were assessed during the time. Actually, the study continued during the initial comic covid pandemic. And, uh, we obviously decrease the number of people that we start seeing during that time. But we managed to finish it. 30 people were enrolled. 15 inch group one patient withdrew consent Day three. So outcomes are not reflected in this. And what we found was that the average age was 59 Age age rains ranged from 36 to 73. Uh, in the majority of them were meant there is everybody having BF public location was 50 50 with home. About 75 to 85% of these people into groups were witnessed. Bison CPR was about 80 to 85%. So high. Bison CPR, eight. All of them were either intubated or 100 metric. Uh, sorry Super agnostic airway device, epinephrine dose and the other than doses. Number of socks were identical in the two groups time from cardiac arrest. The first shop was also very short 7 to 8 minutes, about one in five or one in three patients had intermediate runs before the arrival in both groups. And the MSC in time was 22 minutes and transport time about 15 to 20 minutes. Sorry. 20 minutes. So a total of about, um, 40 at least 40 some minutes before we, um the decision was made to transport until arrived. The hospital. The organization was done within 50 minutes. Um, for the control group average GP adulation from now. One called to either being called dead or having rascals. About 80 to 83 minutes. Some very long recess stations. They exhausted any possibility of survival. Sorry. Um, and then if you went to the Catholic because of the ECMO, um, you were into the Via ECMO. You initiated Acma within 59 minutes from 911 call in time from optimization to ECMO was 12 minutes and time from Catholic to echo was seven minutes old. People went cardiac angiography in About 60% of them had disease. Predominantly di disease, as we described before, Survivor was 43% 6 or 14 in one group and one survivor into the control group. And at three and six months, we had no survivors in the control group and all six patients survived and, uh, had good biological function. This is the probability of survival. You see, effectively that no one leaves the hospital, admitted its get admitted or leaves the hospital with the control standard method. But we need all these people and they died in the hospital or they survive once they live to, uh, improve their outcomes over six months and be alive, all of them during that time, which stands through to this day for all alcohol of patients, very few people will start die subsequently with outcomes higher than L. But the populations over three years and significantly higher than transport populations, which we're going to present the data soon. Okay. Obviously, the limitations are this is a single center, very highly experienced in the visual critical care team that may or may not be available in every place. Um, generalization needs to be evaluated in other communities, communities and the local system structure is very important. Obviously the ECMO alone is not the culprit. Is the system in the critical care in the pre hospital and hospital operations in cohesion of the system? Um so from this just a few years ago. We end up being into this evolution of, uh, you know, doing something with a pair of hands to basically bringing the machines in. And from some breaths and compressions and a lot of praying, we end up being in this situation where things look quite compacted in the ICU is nowhere to put anything else for these people to survive. Um, so there is a year of the machine has arrived, and, you know, uh, it's not much machines everywhere the pre hospital setting. If you think about the the complexity of the system in order to receive a patient on time, treat them and survive them. It's staggering the levels of complexity, machinery and people involved in communities. And you takes a lot of villages effectively to make this happen. This is a Catholic just show you that the cath lab is transformed effectively now in the arrest trial and currently into a trauma bay where you know, the the traditional sense of sterility that exists, uh, does not exist. And for us, it was an adjustment, I would have to say, and for me personally, but there's no other way in the you know, the idea is medics, at least, uh, you know, a six men fire fireman medic team arriving with a patient. It's an event in the cath lab. There is a lot of huge bodies, you know, people with a lot of equipment, and it just does not seem natural for the Catholic, but it is what it is, and we have made it efficient. Um, and then, you know, I don't I just want to show you that we used to cutaneous access with ultrasound guidance for intervention lists and fluoroscope pick, uh, you know, you see here using ultrasound, um, amplats wires extra see if immediately with them doing CPR to have to play all the details. But we verify position was before with X ray. And I think this is the main difference between all the cardiology based programs. I don't know how many they are, but our program and the E. D based programs, which is so different from what I'm showing you about what we're doing now in the most department, um, the skills of individual biology to get access in, uh, moving patients of these patients and dealing with, uh, complicated. Um, vascular access is unique. And I'm performing a social experiment and see if this can be taught to other subspecialties. I'm not sure it's the case, but here you see the verification of the wires going to the aura in the I V. C. And then you know that you can dilate safely. You're not dilating to deliver putting a Venus kind line to deliver or in the kidney. And you know you need an assistant. Obviously, you cannot do this by yourself. But what I'm trying to show you here is that, uh, most of you have experienced or seen ECMO calculations. But, you know, it's not uncommon to have this done within four minutes from being on the table. Um, so you know, it's doable. The fastest time from door to echo has been two minutes and 20 seconds in a young patient, thin and everything. Everybody was telling you the day, so it can be done very fast, and it can lead to a lot of, uh, saving of time of the station effort. So the the equal program had a long, um uh huh. Reaching far reaching effects in our program. So this is a 63 year old patients that had a stem in a different hospital. They gave lyrics because it had Perry for a vascular disease. I don't ask me why that was the case, but then so deteriorated overnight. And one of my international colleagues that was a call was brought in as he opened up the artery. The balloon There was a perforation and there was tamponade, the p A. He put a balloon pump up. He drained, as you can see with the drain, the pericardium. And then he called me as I was walking in the movies with my son. Like an indirect No, I said, Okay, well, you know, every time I give up in reference to get some possibility and I drained, but now she's in pay arrest. I have a balloon up in the R. C A. When I drop it, there is, you know, blood coming. So what can we do? I said put a look as bringing to the university so you can see here is patient about 60 minutes after the arrest. Uh, phone call is with ongoing CPR and P E a arrest, and we have financed them back and forth or neck Ma. Now and, you know, we were able to wire through the perforation extent basically lead you a decent outcome with asthma support. While you know, was in this case with a pericardial drain. There was no more bleeding, and there was a minute of the hospital. And this is the patient I showed you earlier. Full of machines. Um, she was in one month in the hospital. That's one month Ejection fraction. Second ejection fraction. Very good recovery. But, you know, the cinema I she was unresponsive, intubated with fever and all failure. People say this is really bad outcomes, a lot of injury, and, uh, we were ready to actually withdraw. We gave until Monday and Sunday night. This woman wakes up and she started talking the next day the next day and two months later, uh, she's in the clinic, and she was a previous nurse, so she had a lot of opinions about her care. And so it is. They're struggling. What we don't know, and I'm not saying every neurological injury will recover. Um, it's really devastating, but those people tend to die early, especially with everybody. Dima, there's no reversal. Okay? But there are patients, Um, that, you know, presenting weird, you know, situations. There's no real good hope for survival. This is a patient that presented with chest pain and shortness of breath. Paramedics, thoughts. He was having an anxiety attack, and they gave her to breathe into a into a bag clean. Upon arrival, she arrested, and then she was brought in with ongoing CPR, and we didn't find in the coronaries. But I shot the This image here kind of very scary. And you can see there too. Uh, the image here mass ipi bilateral. We did a throwback to me. This woman survived. Um, it's sad and death. And sometimes, you know, when there is no coronary artery disease, do we see bizarre cases like this one? Where we have for some reason, was a presentation for a Sydney Yorick dissection. And obviously at that point, with some recipe and you're done, you don't continue. Um, But as we moved on and we realized that make sure that the time is getting ready. The importance of time was, uh, what we try to resolve. So we created this. Minnesota Mobile is a station consortium where, um, we provide services throughout the Twin cities through a non profit company that is co owned by four healthcare systems. And the idea is to provide the expertise, the training, the equipment in the schedules to provide a team to respond to all the patient emergencies in the Twin cities in different emerged departments closer to their, uh, site. So the idea is quite simple but complicated to be executed, that's for sure. Um, you have a cardiac arrest. The medics that that I have there identify the patients and its ability. The radio into a central dispatch were radios to the mobile ECMO calculation team that is responding to three different hospitals. And we meet with Rendezvous at ECA Organization Hospital in the periphery, with the hope to shave 10 15 minutes from the transport and, um, ongoing Sapir. For these patients, we can read emails department with Flora Skopje and equal machines that are available there 24 7 by the program with microscopic table bought by us. Um, that it's easy to move in and out emergency department, and they transform an idiot room into an a calculation room effectively, and then once this is done, we go to the Catholic in that hospital, and then we transport to the expo center. The idea this was basically to save time to allow hospitals to participate in this patient. So there is no competition, um, but provide the best care, allow revenue to be generating the pitiful hospitals so they can collaborate and then realize that taking care of these people requires a much higher level of care. And most of this hotel did not want to deal with this, So it was easy to have a single centralized NYC. You center. I won't really bother you this at this point because it's kind of similar to before, but effectively were able in four months to do 63 patients, um, evenly distributed among the other hospitals. About one third the meats hospital. And, you know, we saved about I would say 10, 15 minutes from number one to arrival was, uh, 45 minutes, compared to 50 minutes, 55 minutes. And those, uh, you know, 56 minutes. Did they make a difference? I don't know yet. The goal is to be able to calculate within 45 minutes, Um, as we do more and more and the pandemic dies, away. Hopefully, uh, we will be trying to facilitate Expeditiously, um, the teams there in calculating faster. Um, we tried to calculate within 15 minutes, Uh, and we met all the criteria. Survival was about 42% again, Um, and, uh, you can see here 47% Sorry. 43% good functional survival. With most of these people having CBC one and two. This is what it takes for this. You know, we have a team of critical care doctors, paramedics, uh, and Eddie docks. Then we have chase vehicles. So the team goes there with sirens and lights. We try to train them before they have an apprenticeship kind of process for me in the middle here. And my partner, Jason Bartos, experiencing the visual biology have done about 1000 of those the last five years. We have what I call every other week with the positions while we train them on the job, supervising them eventually. No one has graduated yet because of the started going, but the goal is the next six months to see which of those physicians have the skills and the commitment to do this. And then, uh, we'll have the group of total, I think 6 to 10 positions or we can take call as part of our job to serve the city. Um, Then we will have a financial sustainable model where we have revenue to support this from the hospitals as part of their income from this patients that they arrive. Uh, we have, uh, three ways of doing it in the center is the cath lab. This is the setup very similar to the Catholic that we have, um, into the merge department. And now we have moved to have a track built to assess the idea of not moving the patient. But send the track to the patient site with the hospital basically being there with X ray here, ultrasound access and all the bells and whistles that we have in the cath lab. Obviously, um, it's a big truck. It has to be driven by firefighters. And so we have to work around the process of how we get there on time and all those things. But that's the idea. Um, this is how I roll to work these days. And, you know, if you want to to look at that, you can go to this video, and you can see the details of the track inside as we're building it. It's just an interesting concept because of the capability that it brings us much faster to the patient. Uh, today we have done about 356 patients are Survivor has dropped a little bit, especially during the covid time. As expected, we have about 36% survival rate. Average CBR is about 55 minutes, and these are two of our survivors, a 26 year old with, uh, lactic of 20. But the younger you are, the more forgiving we are for the profusion criteria. And he's actually a dentist now. And he has a group, uh, group practice. And he's doing very well. Another patient here, about 62 minutes of CPR, 93 days in the hospital. And, you know, he he sent me. He just sent me an email about his fourth birthday. He has a a second birthday now, So just for the finalized all this by saying the ongoing CPR and easy unless it's like free falling. The longer you fall, the higher the likelihood of dying. If there's no one there to catch you, you're doomed. And now we have a safety net called easy or less. In the earlier you apply it, the more likely you are to survive this catastrophic event. So I'll stop here and take any questions needed. Thank you very much. Alright, Dmitry, That was fantastic. Um, great talk and thank you for leading the efforts and really pushing the envelope in what we can offer these patients. You know, it's interesting. As an inter metro cardiologist, you see the group of patients that come in with an Emmy and they've had pain for 12, 24 hours and they tend to have very large in FARC's, even after revascularization. And then you see this group of patients that comes in with the F that happens as soon as the artery includes. They tend to have very small mes Um, the problem is not my cardio recovery, but it tends to be neurologic and other organs. And so I think you're your efforts are really crucial in how we treat those patients. Yeah, absolutely true. It is kind of recovery is not an issue very early. Very late presentations with prolonged use of station do have a toxic effect. Of my current proponents of 200 or more over 200 are commonly associated with characters function, but with brain death. So it's a market of a very severe global hypoxic event. And, uh, the you know, a thing of contention. I just gave a talk to European Society of Cardiology about this, but it's like we never meant ventricles. The ventricles have zero ejection, fraction of executive fractions, 12% the first day. But they all recovered to 45% of people that survived, and we have never prevented any of our patients. And that has been always a, you know, an issue of contention. But there was no never an issue to solve. Like we don't see ventricles dilate or having If they do have a I they die. Uh, you cannot really say these people and we don't know when we put economic they have a I c v a. I. We had one case. I had a metal, the aortic valve that was stuck in the open position we put ECMO. Whatever you're putting in was coming out of the mouth was impressive, but I don't know the correct recovery is not an issue. As you're saying that within their, you know, bad luck of having characteristics. They are fortunate when they survived, because they really because they come so early. Revascularization very early. So they really have very minimal s t elevation related micro dysfunction. You're absolutely correct. I've got some questions on venting, but we'll come back to that August through practically how you guys set up your program. And what I mean by that is a patient comes into the emergency department with VF arrest. They're having Lucas CPR done. Who do you have a profusion ist in house? Um, do you have the interventional team in house? Who puts them on ECMO? And you alluded to the fact that you do a lot of this in the emergency department, as opposed to transferring a patient, you know, upstairs to a cardiac cath lab. So they're the logistics of you do that? They're Currently there are two models. One is at the university where we actually first of all, all the calls come to us. There is no image department activations for the F B T happened between three interventional cardiologist effectively to mechanization. Because we are the Yeah, the center for the station medicine. Uh, you know, leadership. So we are connected into the dispatch. So medics identify somebody in the field, they call us, and we basically activate the VF system. Um, so effectively, it's a high burden for a small group of people to be available all the time. We are cute, too, on this, but it's cutting the phone. It's not a big deal for us when we go vacation Macari. But it might be an issue in bigger groups. Um, because we activate we bypassing department if we're there and we have a 20 minute response time for the cattle about the university. We have sirens and lights so we can get there any time. My transport time without science lights is 20 minutes with sirens and lights is seven from home. So it's just a very different strategy. And we've focus on this because without it, you know it's good to have a physician being there when patient arrives to get this idea what's happening? So there is a lot of personal involvement. Everything gets done in the Catholic at the university, not in the midst department we don't need perfusion is to start. We have ECMO specialists that they're always in the house and they come down. But before all this happened, when we started the program, I was starting. React when? Minutes in the ECMO. Um, you have to be able to do that so much you can relate. You can tell people to dial up the thing, right? It's all primed and ready to go. Um, well, I was waiting for the patient most of the time at the bubble and circulated for a couple of minutes and have it club. They're ready to go. We trained our Catholic stuff to be able to just give us the tubing. Um so depends on how your system works and what is available and not you can work around. They need to have one. Profusion is come and do this and starting it is easy. Um, profusion is can take a longer time to come there if you have to. And you can play somebody emerged department, a little different beasts because the Catalan has small teams that you can train emerges department has every time you go to merge department. There is somebody who has never seen this before and they're looking at you like you're some kind of alien. So it is. You have to depend on your own team, and we bring basically, you know, three team or three people to do this. And once we are in the G. D. This is our patient. We don't You know, the rest of the team is there to help you, But you have to remember, even simple task is getting an arterial line and measuring the arterial line. It's a task for the men's department compared to the cath lab. Um, so they're not used to the speed and the X rays and all the stuff. So it is is a challenging environment to work in. We managed to make it work. Is it optimal? No. But I think the more we do, the more we understand it. You can do that image department, but you need flora Skopje. I'm not gonna super sugar coat. You need to have the ability to see where your wires are, because once you fail the first calculation, the wire goes and go, you can screw. There's nothing you can do in the most department. And the idea. You can identify that with ultrasound and thi this is this is emergency medicine document which is not true with a moving patient, you know, different body habitats and very complicated atoms. Many times. Dmitry, you talked a lot about patient selection, especially those that present with VF. Can you give us some idea of how many patients you turn down for ECMO? And if outside of the three criteria being Lactaid, uh, and Title Co two in the p 02 is there anything else you used to exclude patients either their Glasgow coma scale or other markers? No, Uh, you know, history, first of all, is very poor predictor in pre hospital, you realize very fast that medics will tell you best intentions are to tell you what they think is right. Sometimes you know, the imagine seeing things, so it is very difficult to nothing against them. I love them and work together very closely. But there is a very stressful environment where they're working, and the details that you are getting from pre hospital there is very poor. So I only want to know. What the first rhythm is even witnessed is a very complicated situation because people say it's weakness. I heard my mom thump upstairs, but you don't know how can you hear those things? And when it is and you know you go down and find your mom was five or 20 minutes down, you know you're gonna make decisions with those things. So that's why we have the profusion criteria. They're not perfect, but they are. Okay. Uh, you know, we used to exclude anything non cardiac, like, over overdoses or things like that. But we start seeing a lot of overdosing young people, and we start doing this and we had so success. So initially, we're excluding all these people. So as you do more and more than you should have potential. Unfortunately, there is a creep effect which is very difficult to man. It's especially hypothermia. You know, you found this 16 year old kid under a lake about a month ago. 14 degrees Celsius. It was a Popsicle. We are, you know, do we know if it's going to work? We did it. It didn't work. But that's that's the problem that we face. And it's true. Whenever you have done some cases outside your scope and the, you know, why not try this on this one. So there is, uh We have stayed away from P and a sisterly because there are too many people with poor prognosis and there are too many of those. But we're starting to investigate the possibility of going into p A younger people faster arrival times and, uh, witness and bystander CPR because they have peace. Sometimes they have coronary artery disease, about 40 to 50%. I've done about 20 of those, and there is also some evidence that they have called reactive. This is the presentation. And so we'll give it a shot with Pia. And I'll tell you for five years what that means if we are operational. But we try to stick to their in general, about 9% of our SCP Our patients are within protocol, only very young people. We will divert the protocol. So you mentioned a little bit about patients that present with other rhythms? Um, I think we are. We all struggle with this because we have all seen patients that are young. Um and once they're on ECMO, we found that they have a PE and or something. That's what I consider treatable. And and the ECMO is a nice bridge to support to a treatment. Um, and we've had young patients that then go on to assemble ectomy for their PE or some kind of catheter based therapy, or something that's readily reversible. You also have the patients where they're presenting, and it's not clear what's going on or it's multi organ involvement. Or it's a decompensation of a chronic cardio myopathy, which the prognosis is very different because in those patients we don't have a quick, short term fix to their problem. And so we struggle with the same thing on how to identify these patients. And what's the best patient outside of the clearer VF acute coronary syndrome to offer this to? Yeah, I think you're absolutely correct. It's very hard. And but experience with the programs start. If they start developing, um, they will find their ways. And you know more people will have more experienced collective experience and share some experiences. Right now, you know, there is another limitation, which is volume of patients and access to beds and ECMO machines. So, you know, if you open your program to P A. R. S, and that's what I struggle, there's no way to put them there too many like you. Well, how many times were closed like last night were closed? Because we are on 12 drachmas and there is no way you can. There's no bad. So if I and that's only the F in our cardiogenic shock related cases or transports, right, you have the same issue. What are you going to put all these people? It's a lot of people, especially with, you know, the pandemic. We saw a lot of younger people having alcohol related or drugs related characteristics. You know, we've said some, but if you start doing those, this is a very slippery slope as far as resources. So it has to be done with experience and expertise in the center and probably collective discussion with the administration about resources because they will consume a lot of resources. Dimitri, I'm going to close with one final question. I could probably talk to you for hours on this topic, and, um, we would love to have you back at some point to to continue things. We're all balancing outcomes with metrics such as NCD are and how hospitals are ranked and rated, and one of the things that we struggle with is in the acute my population. It's the out of hospital arrest that really has a higher risk of death. You hear about a lot of hospitals with risk avoidance now. And what's your view on this? Because it seems like we're going to potentially not offer treatment to a lot of patients if we go down that path, and how do we balance that with with outcomes? So, man, you know I have Well, there are some, you know, logistical ways to get around this, which I use a lot. We exclude these people because, uh, you know, there is now in the A C. C database check box that says the cardiac arrest. And we have friend CPR and automatically puts in different situations. What you do get penalized the CMS. So that's for a fact. If you call it, I keep my car infection. I don't call it like you, Michael. Infection. I don't have any kg. I just you know, I said, this is a B F. R s. We go to the Catholic with fixed coronary artery disease. There was, by the way, coronary artery disease presence and I stay away from the systemic classification because, really, there is no rest to me. I have a V a patient. So if you want to be the realities, I can try to do what's best for my patient. And when administrator comes, say the mortality for these populations high, I say, Okay, it's high, but, you know, so is an aortic aneurysm. But we operate on them, you know, half of the people with operations, they will die if you don't operate on them and you know about 20% or whatever. They're going to die if you operate on them. But certainly still do it because the right thing to do so I think it's a little balancing of finding ways to circumvent the stupidity of the reporting systems until they adjust to the reality is because they do a just. And there has been a big discussion of, uh, the SEC databases and the N. C. D are the basis to eliminate, to put it in a different site. And I'd say we CPR and characterized to go to their own, uh, situation. It's not the same that you saw. This survival is half if you have the F even simple non stem e arrest. Right. You will have 40% survival in the best case scenario. So you should not be penalizing care because you lump together a 99% survival with 10% survival population. That's really scientifically flawed. And we should try to fix it. And I think it's up to us. Thank you, Samir. All right, A fantastic talk. We really appreciate you coming virtually online today to speak. Um, have a great day. Happy ST Patrick's Day to everybody. And Dmitry would love to have you back in a few years. Uh, more. Thank you. Thank you. Everybody. Have a good day and stay safe. All right. Thank you.