In this video, cardiac surgeon
Christian Bermudez, MD, examines extracorporeal membrane oxygenation (ECMO) and shares how to delineate when the VA ECMO is the best option of support. He also touches on other considerations that clinicians will be faced with during the selection of devices. Clinical scenarios and cases are shared during this video to provide real-world examples of physician decision-making.
@PennMDForum This is gonna be a clinically focused talk. I know we have, I don't know, 200 or more, you know, virtual attendees and they want to hear when, when do we use VA E compared to other devices? So it's gonna be really focused on clinical uh scenarios. Uh So when is E C O the best option in cardiogenic shock, defining clinical scenarios? Uh This is the outline basically in the introduction of T CS and in cariogenic shock. I'm gonna talk about uh the different D A methods of support considerations and limitations of different va E methods. Talk a little bit about the phenotype. When do we first think E C when they call us rather than other devices? And I'm gonna give you three clinical scenarios the objective again to understand for the general practitioner doing E C O. When is E C O the first option? When do we think and the other complexity as we're seeing combination of devices, when do we think escalation of support versus the escalation? As you know, the number of, and I mentioned before, the number of support devices using cardiogenic shock has continued to increase about 35% of the patients in the ic U today with cardiogenic shock or with Nick Shock will require some sort of mechanical support more often in balloon. But the number of other devices including and Axio flow pumps has continued to increase fortune for us. These two technologies today have taken, you know, preponderance in terms of mechanical support, they're very stable and they're providing really reliable outcomes. So we're gonna concentrate on, on these two. Doctor Seva will be expanding on the impella 55. That is the new uh kid on the block. When do we consider a temporary support? Er Doctor E W talk a little bit about it. Uh in general in advanced stages of shock stages, CD N E. This guy was I brought two years ago, three years ago, a more understandable definition of cardiogenic shock that makes it easier for us to identify this patient population. More recently, Naidu and colleagues publishing Jack a consensus, adding other parameters, inflammatory markers, lactate parameters and others to understand better. When is a patient is stage CD or E facilitating our understanding of this. But conceptually, we use temporary support when the patient is hypotensive in spite of, you know, adequate volume resuscitation in general with one sometimes in two isotopes with low cardiac index, a low PAP in the case of R V failure and uh with elevated a wedge pressure in general associated with lactate. Now, we know that we're gonna have different levels of lactate to be able to define better this population. But we know that when lactate start building up, you start to start time to start thinking about mechanical support. We learned from the cardiogenic shock working group. And this is important data as we understood better, the stages of shock that things have changed over the years. We used to think that in general, this was associated with the I only mostly L V dysfunction. But as we start putting swans and studying these patients better, we started to see now that the most frequent cause of of cardiogenic shock is not acute M I is acute on chronic chronic heart failure, they compensate it. We know that they present in general in stages D N E more than 50%. We also know that the majority of them are a vast proportion of them presented by ventricular failure. And that may be the reason why continues to be a very frequent and and utilized option of mechanical support. We didn't know that this number was so high. So 50% today present with biven trigger failure. And that's the reason why also we're considering combination of devices. The selection is been uh a a has varied over time, but there's some criteria that we use the type of presentation. What ventricle is failure again, is it single ventricle failure, biventricular failure again, with a more important role in this biventricular failure, the urgency uh the ease of the implantation, patient characteristics, obesity, vascular axis, important. What type of support patients with, you know, a a by ventricul this function in septic shock, they need high flows E C O may be a good option. And what are the devices available? We talk about cost of these devices and what are the devices that your institution is equ in managing and what are available to you in your place? And if you look at that E C in general, You know, is present in all these stages and is con can be considered basically in any presentation of cardiogenic shock. Today. Again, we have other options. The impella 55 has taken a preponderant role in the in the management of cardiogenic shock. And we're gonna be talking also about that in the next session. When you look at the at the stages of shock that are supported on in general, you see that stages e you see that 73% of the patients supported are gonna be supported on epo alone or in combination with other devices in stages D it is about 17% of the patients that will be supported on EPO. That's what we start thinking of va point advanced stage. The classical indications have continued to expand. We started with postcardiotomy shock in 30 years ago, we evolved now to a Q I myocarditis A E CPR A, a big big topic and Doctor Yiannopoulos gonna be expanding on that embolism, et cetera and now breed to heart transplant. And also is taking a uh uh a very important uh proportion of this patient. But that is really depends on the center is very variable. So don't get confused by the numbers because it varies among the institution. Now, this is our experience. We do about 250 at hub in two hospitals and this is the hub data, 160. And if you look at this different to other series, about 20% of these patients are postcardiotomy shock versus 33 or 30% of the patients being E CPR And combine M.I. acute chronic also around 30%. This would be different to other series because things change among the institutions. They are different patient population. It's important to know not just when to use it, when not to use it. And there's some criteria that's specific to the patient. If you have a patient with active bleeding, not able to get anti coal. That's a contra indication today for EPO and rep period dissection, we should not do it severe peripheral vascular disease. A patient that we're not thinking in peripheral potentially central cannulation if possible. And you have time and severely oration of could be done. Today, we consider still a contra indication that other factors related to the patient. A patient that is not a candidate to any other I I support option or winning. It should not be considered. But you can read there than a number of other patient specific contradict. Now, the the advantages of of the other percutaneous option is that is rapid insertion. The flexibility of support can provide right or left and trigger support, fully dynamic support, provide support when the lungs are failing in terms of congestion. And there are other modifications of V E F or the so called V ad mode that I'm gonna show you in a minute that could be used in the circumstance. And again goes back to also a low cost compared to other options. The most frequent calculation strategy continues to be femoral femoral, but we need to be aware that the other options are very uh helpful. A axillary femoral cannulation is recent data showing high rates of talk. But it's still a useful strategy when we don't have access on the growing karate femoral, mostly using pediatric and central cannulation that we still need to consider uh because it's helpful and we have data now showing that could be as safe as peripheral cannulation. And remember that when we look at the the amount of oxygen delivery and innam support central va continues to be the best option. Again, most frequent peripheral, this calculation is used in great proportion of our patients has decreased about 15% of the risk of vascular complication. We use it with near monitor to decrease that. A lot of data has been published with this strategy. Uh in general. We survived between 2025 and 65%. A number of those patients going later to a or to heart transplant. More recently, about 6% of the patients undergoing a heart transplantation. But we need to be cognisant that peripheral D E has some complication. First of all, it is a short term support. Uh We see this is data from significant drop in the survival after 10 days of support. So we need to start thinking after 10 days, what is gonna be our next strategy if that patient is still not recoverable. We also know that in spite of the use of diesel perfusion catheter, uh there are still significant vascular complications, not just distally, but we're seeing now central ischemia glutose, we're also seeing a spinal infer in some of these cases. So again, not a free, right, not just the vascular complications are important in peripheral. Also, the fact that we provide retrograde flow is associated with increased and diastolic pressures as shown by, by doctor Ray, his previous talk and that has some consequences including the the potential for thrombus formation, the inability to wind or or a load. Their heart may have consequences in terms of recovery, the formation of thrombo in the root, central hypoxemia, the North South syndrome And the risk of hemorrhage. So, about 20% of these patients will require some sort of ALV and loading. Now that severe dilation has consequences if it's severe that happens in about 10, 10 per 7-10% of the patients that would be associated with lower ability to recover the heart and with higher mortality. So, we need to be proactive and the number of techniques I'm not gonna go over them. Usually today, the use of Axio flow pumps. Also the use of direct a can through a small economy that are probably the most used today. A unloading the ventricle in that circumstance is associated. And this is a paper published a few years ago by Papa. That's been quoted multiple times with better survival. A less a higher ability to win the patient with a mechanical support and higher a ability to get to the next therapy or recovery. So still, we consider we're very proactive on loading this patient not necessary in all cases but do not forget central cannulation. Uh The anti grade flow has some benefits and sometimes we drag our feet with a bad, you know, peripheral cannulation strategy with point congestion. We need to revisit this. Uh the fact that we're doing this now with central graphs using even for a loading A this skit uh has decreased the number of of patients in bleeding. Uh it allows us to transition to other options later to RV, et cetera. They used to minimal of minimal invasive techniques as you see in the screen. And this was popularized by the group in UCLA with 88% of these patients being mobile has really changed a little bit. The approach of some centers to central can been data showing uh that there's no difference in survival between central and peripheral. This is uh a metasis of 1600 patients Uh with higher rates of transfusion, more hemo analysis but still no difference in survival. Another actually paper showing us that central cannulation may be or may have better outcomes at 30 days and peripheral calculation with minimal bleeding at the site of cannulation, especially when using this graph. So keep in mind that this is a safe option when done properly. And this is one of our patients that you know, we were able to uh keep for 45 days walking in the ac U while waiting for transplant. Remember the other option of A VA V E for those patients with a congestion, it's important to have this in mind. Uh It's tricky to manage. You need to keep partial flow on the on the arterial limb to manage a give two liters at least on the A I G A arm. But but it's an option where you have congestion. Again. If we go to the phenotype of patients, if you consider the clinical presentation, presence of arrhythmias or other or the urgency, the degree of extension of the cardiac dysfunction and the level of type of support and and vascular access needed. The classical phenotype of a patient when they call you is a patient that is in sharp unresponsive or rapidly progressing, usually D O E unstable with severe left, right or bi ventricul dysfunction plus minus hypoxemia and with good vax AIS. That's when I first started thinking of if you go to a specific clinic scenarios, advanced refractory shock. When you see patients already going on renal failure with elevated L F T S, you know, that probably would probably be better served with ongoing cardiac arrest. We're gonna see later, first indication, unstable arrhythmia. And we've seen that with Doctor Garcia today. Uh bringing a lot of these patients with unstable ventricular and Atal arrhythmia. Think of again by tricker this function by tricker this function cases of P when you have hard R ceo collusions that may affect the think about to start a car shot with hypoxemia, mechanical complications. First indication. Now we know that axel flows, we just learned can also be used in in DS D but in general, when you have mechanical complication, va more first postcardiotomy failure, failure has been used for many years. And again, more recently, heart transplant is special when you have risk factors like right sided congestion, trim or L V. Thrombo is when we need to start thinking of va F briefly. I'm gonna mention that V E echo generally today is not used alone, is used in combination with other devices, not only for unloading but very often as we're transitioning from devices that do not provide enough support to higher support and we need to be prepared for escalation and deescalation. So, very often we've seen an impella C P that will require E O because it's not enough or an E that will require an impel A P 55 or, or C P to unload. And we need to be prepared and understand that that's where we are today in this type of uh patient. But also we need to be prepared to deescalation uh from a patient on VA E E that may require V V E because he still has significant congestion or may require a P 55 if he needs more time to recover or to get him to transplant and just to go briefly, some, some clinical scenarios. This is a 22 year old woman that presented to an ID in the region in cardiovascular collapse, cardiac severe by ventricular dysfunction. You see their thrombo in the right ventricle, a diagnosis, a cardiogenic shock S CD and the word peripheral by dysfunction, chest C T was negative left her cat, no coronary disease was diagnosed with COVID-19 myocarditis as there was no, almost no contraction on the L V. It was placed with an impella C P as they were concerned about the potential thrombo formation. Uh She got to our hospital to see the heart was barely moving um on the x-ray. Uh We kept her in six days, we increased the P TT and we have thrombo on the AC P and within six days that uh function recovered, but again, she was not ready to come off because the lungs were still wet. And uh she was transitioned to V V for three days and was discharged a few weeks after in good condition. So be prepared for that escalation and the escalation. Uh a another scenario, escalation from other support to that have nothing to us today. 47 year old patient, recent patient that would transplant progression to heart failure, cardiogenic shock got P 55 to a right axillary approach. Unfortunately, because of this, the right ventricle failure patients started a few days later with alarms not, not able to flow properly, progression of of renal failure. And EMA was initiated, you can see immediately the right ventricle got smaller, the renal function got better. And when a heart transplant on January 11th and was discharged uh three weeks after that uh third scenario, I wanna be aware that make you aware that sometimes all these devices together don't work. And this is a case uh that it had a non ischemic cardiomyopathy. You put an, we put an EL P 55 for support uh listed for auto topic heart transplant and uh it had worse and important congestion was placed on a and unfortunately, uh this was before going to transplant despite of being on full flow in P 55 and 3.5, a flow on the on the uh with severe M R, these were the lungs going to the transplant. So sometimes this peripheral approach is not enough though. That's what I'm saying. Consider uh that we need to start thinking a little more creative than that. And to finalize, I wanna present a case of a central epo. So don't forget central ECMO patients that when an A, a replacement uh presented a immediately uh in on bypass with an ability to come off of a bypass. A uh they suspected an R C A uh occlusion. They did a bypass on the right um uh echo show by ventricul dysfunction but mostly R V dysfunction. For that reason, they put an R V in the O R thinking the L V would be OK. She was admitted to our center, profound poly severe biventricular dysfunction. We transform the R V to a central, just put in the in the order the patient a few days later cleared the lungs, we confirmed the presence of an ablution of V R C A. And within seven days of ECMO support that L V recovered. The R V still was, you know, not functioning. For that reason. We converted back to a central uh to a central as she was already open. We kept her for 32 days and you know, 32 days later, you see both ventricle normalized or near normalized. The patient was discharged home and is doing well today. So in summary, I would like to say that a use in car continues to increase by other options being available. Um E C is the best option in unstable clinical conditions with is important by involvement and with this, the time of support is limited and can also serve as a bailout with other options are not sufficient to correct the metabolic Derain. Despite improvements in technology, E C O continues to have some limitations and we, we need to be aware of them that are important to identify and prevent to improve outcomes. We should be flexible to escalate E O support when needed changing calculation strategy and to we need to adapt to the needs of the patient. Occasionally combining devices is OK. And to finalize if you're hesitant on how to initiate the support in your patient, start with the, you will always look good and can always modify strategy later based on the patient data. Thank you so much.