ECMO IN CHANGE 10th Gulf Heart Association Conference, SHA 24 Hasan Bushnaq, MD Department of Cardiothoracic Surgery Martin-Luther-University Halle, Germany
VICIOUS CIRCLE OF CARDIOGENIC SHOCK
THERAPY GOALS
Heart Hemodynamic
Lung Oxygenation
THERAPY OPTIONS
RESPIRATORY FAILURE CESAR TRIAL, randomisierte multizentrische Studie
CESAR-TRIAL
CARDIOGENIC SHOCK
MICROCIRCULATION AND INOTROPIC Side effects of inotropic: Increased heart rate causing further deterioration of failing heart pump Increases myocardial oxygen requirements
Perfusion Pressure Perfusion Volume Oxygenation Intravitalmicroscopy of the Mucosa
Potentially arrythmogenic Can increase ischemia
Jung et al, Clin Hemorheol Microcirc. 2008;40(4):311-4
IABP AND CARDIOGENIC SHOCK
ECMO AND CARDIOGENIC SHOCK
ECMO AND CARDIOGENIC SHOCK
No randomized studies
SCHOCK UND ECMO
Sheu et al. Crit Care Med 2010 Vol. 38, No. 9
ECMO ECMO is a derivative of the heart-lung machine
Nomenclature •
ECMO Extra corporeal Membrane
oxygenator
•
ECLS – Extra corporal Life Support
•
LSS – Life Support System
•
Temporary extra corporeal support
Compositions
VA-ECMO •
Peripheral VA-ECMO
•
Central VA-ECMO
ECMO PROGRAM HALLE
ECMO HALLE 2006-2012
INTERDISCIPLINARY ECMO, HALLE
MCS PROGRAM, HALLE
DGTHG PERFORMANCE STATISTICS 2011
HALLE - MOBILE ECMO-UNIT
Halle Ecmo Life support Program (HELP) •
24/7
•
Within a radius of 250 km
•
Ambulance or Helicopter
•
Cardiogenic shock or/and ARDS
•
Implanting ECMO on site to be transportable
THE STEPP AFTER ECMO
Recompensation Recompensation
Recompensation Recompensation
Recompensation Recompensation
End EndOrgan+ Organ+ Neurology Neurology++ Heart Heart++
End EndOrgan Organ++ Neurology Neurology++ Heart Heart--
End EndOrgan Organ+/+/Neurology Neurology–– Heart Heart+/+/-
ECMO - Explantation
Permanent Support LVAD/RVAD/BIVAD
ECMO Weaning and Explantation
TEMPORARY ASSIST DEVISES Bridge to recover or dicision
Temporary RV support
Low cardiac output syndrome cardiogenic shock + Indicated surgery
Medical therapy: Dobutamin 5-20 µg/kg/min Noradrenalin 0,05-2 µg/kg/min Consider Levosimendan Adrenalin 0,05-2 µg/kg/min No Dopamin
Therapy LCOS-/shock-/therapycriteria • systolic blood pressure < 90 mmHg • cold kimbs • oligo-/anuria • HI < 2,2,L/mivn/m²
Persistent shock INTERMACS ≤ 3
-
Stabilization, Conservative treatment, Recompensation, Reevaluation
+ Moderate Support INTERMACS ≥ 3
-
Emergency INTERMACS 1-2
+
-
+
Therapy
IABP
ECMO
LVAD
Device
1-2 l/min
2-5 l/min
10 l/min
Route
Percutaneous
Percutaneous Or surgical
surgical
2- 7 days INTERMACS classification of heart failure Level 1
Critical cardiogenic shock
Level 2
Progressive decline on inotropic support
Level 3
Stable but inotrope dependent
Level 4
Resting symptoms on home oral therapy
Level 5
Exertion intolerant
Level 6
Exertion limited
Level 7
Advanced NYHA class III
Weaning (see Box)
+ Explantation, Stabilization and Further therapy
-
CONCLUSION
The ECMO systems have a fixed integral part in the treatment of
cardiopulmonary decompensation. The ECMO system can not work magic, which are as good as the patient and
the user. Crucial for success is patient selection and the time of implantation.
It does not matter, to give life more years, but the years to give more life. Alexis Carrel
ISCHEMIC CARDIOGENIC SHOCK AND ECMO Operable patients with cardiogenic shock as a result of myocardial infarction
DECOMPENSATION AND PULMONARY EMBOLISM
Failure of the right ventricle
H. BUSHNAQ
6. Apr 2013
FALLVORSTELLUNG
Alter 18 Jahre weiblich Lyse refraktäre
hämodynamisch relevante Lungenembolie
H. BUSHNAQ
6. Apr 2013
H. BUSHNAQ
6. Apr 2013
MITRAL REGURGITATION
H. BUSHNAQ
6. Apr 2013
EC No M O
EC M O
ZUSAMMENFASSUNG
MCS-PROGRAMM HALLE
CARDIOPULMONARY SUPPORT Temporary Support Heart und Lung V-A ECMO
Permanent Support •
– LVAD • Pulsatile or non-Pulsatile – RVAD Pulsatile or non-Pulsatile
Heart V-A ECMO Abiomed BVS5000
– BiVAD Pulsatile or non-Pulsatile
Biomedicus Bio-Pump Impella 2,5 und 5,0l TandemHeart Lung V-V ECMO V-A ECMO
Heart
•
•
Lunge – !!
TAH
TIME OF IMPLANTATION Cardiogenic Shock
In refractory cardiogenic shock Definition: MAD < 56 mmHg end-organ dysfunction
(Kidney, Lung, Lever) PCWP > 18 mmHg CI <2,2
Sepsis
more ≥ 1 Organ dysfunction Cardiovascular Refractory Hypotension
Renal Respiratory Lever Hematological CNS Metabolic, Acidose
PREDICTIVE PARAMETER
Wang J, et al. Ann Thorac Surg 2009
ď&#x201A;Ą Lactat
Paolini G, et al. Interact Cardiovasc Thorac Surg 2010
PREDICTIVE PARAMETER
Liver function
Höfer D, et al. Transplantationsmedizin 2004
MCS-PROGRAM IN HALLE n=602