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Bridging VA ECMO to Durable MCS: Keys to Success
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The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
patients developed refractory LV distention with pulmonary edema despite maximum medical treatment and required either atrial septostomy or additional mechanical support. Minimum PCWP readings during pVA-ECMO were 12.8 mmHg (11.0-14.4) in patients without and 10.0 mmHg (8.017.0) in patients with need for dMCS (p=0.236). Minimum LVSWT during pVA-ECMO were 2.7 £ 105 dynes/cm (2.0-3.5) in patients without and 3.5 £ 105 dynes/cm (3.1-4.0) in patients with need for dMCS (p=0.002). Adjusting for age and race in a logistic regression model revealed that only post-cardiotomy pVA-ECMO and LVSWT, but not minimum PCWP were independently associated with need for dMCS after pVA-ECMO. Conclusion: We show that strict medical management can lead to LV unloading, i.e. minimum PCWP < 18 mmHg, in the vast majority of patients requiring pVA-ECMO for advanced cardiogenic shock. However, high LVSWT during pVA-ECMO remained predictive of need for dMCS even with unloaded LV.
407 Bridging VA ECMO to Durable MCS: Keys to Success A.M. El Banayosy, M.M. Koerner, D.A. Horstmanshof, A. Phancao, B.V. Jassman, C. Elkins, J.W. Long and A. El Banayosy. INTEGRIS Baptist Medical Center, Oklahoma City, OK. Purpose: There is limited data in the literature defining criteria for bridging advanced cardiogenic shock (ACS) patients supported by veno-arterial (VA) ECMO to durable Mechanical Circulatory Support (MCS). We evaluated our screening process on outcomes for all patients at our center bridged from VA ECMO to durable MCS. Methods: From September 2014 to October 2018, 153 patients received VA ECMO for treatment of ACS greater than 24 hours. Care was withdrawn from 64 (42%) patients, 68 (44%) were successfully weaned from VA ECMO, 4 (3%) were bridged to extracorporeal biventricular assist device, and 14 (9%) were bridged to durable MCS, which were included in this retrospective analysis. All 14 patients accepted for durable support implantation underwent a multidisciplinary screening process. Criteria for candidacy included 1) acceptable end organ function, 2) extubation, 3) negative infection surveillance, and 4) neurologically intact. To compare clinical status pre VA ECMO and pre MCS, end organ function was assessed by Sequential Organ Failure Assessment (SOFA) score, lactic acid, renal, and hepatic markers. Outcomes assessed included survival and post durable MCS implant hospital length of stay (HLOS). Results: As of October 2018, 11 of the 14 patients bridged to durable MCS are still alive (79%). Mean duration of support on VA ECMO before transition was 11 days § 5 (4-22), and a mean of 343 days § 312 (28-1041) on durable MCS. The mean post MCS HLOS was 29 days § 20 (9-90). Of the 14 patients, 11 were transitioned to LVAD. One patient was explanted due to cardiac recovery, 1 received a heart transplant, 1 deceased, and 8 are still on LVAD support. In 2 patients, temporary RVAD support was required post LVAD. Three of the 14 were bridged to Total Artificial Heart, of which 2 have died. Conclusion: Applying a thorough screening process to INTERMACS level 1 patients bridged with VA ECMO to durable MCS is a highly successful strategy and yields excellent long-term survival. Our screening process might be a useful guide to bridge select VA ECMO patients to cardiac transplantation.
(Continued)
White blood cell count Platelet count SOFA Inotropes ≥1 Mechanical ventilation Age Sex
Pre VA-ECMO
Pre MCS
P Value
18§10 227§116 11§2 14 (100%) 14 (100%) 55§15 (21-73) Male: 12, Female: 3
11§5 122§72 7§3 4 (28.6%) 1 (7.1%)
<0.05 <0.05 <0.05 n/a n/a
408 Hematological Complications of Impella as an Unloading Device in Patients with Cardiogenic Shock and Veno-Arterial ECMO. A Systematic Review and Metanalysis J.E. Pino,1 E. Grajeda,1 F. Ramos-Tuarez,1 S. Sundaravel,1 S. Sehatbakhsh,2 E. Donath,1 and R. Chait.2 1Medicine, University of Miami/ JFK Medical Center, West Palm Beach, FL; and the 2Medicine, University of Miami/ JFK Medical Center, Atlantis, FL. Purpose: Veno-arterial extracorporeal membrane oxygenation (VAECMO) is commonly used in patients with severe cardiogenic shock. However, left ventricular unloading may be impaired due to an increase in afterload caused by VA-ECMO. Impella has surged as an unloading device in this scenario but, its concomitant use with VAECMO has been associated with a higher risk of bleeding, hemolysis and acute kidney injury (AKI) requiring renal replacement therapy (RRT) in these patients. Methods: This is a metanalysis and systematic review that aimed to evaluate the hematological complications of the concomitant use of Impella and VA-ECMO in patients with cardiogenic shock. Pubmed, Cochrane and Scopus data based were used. Primary end-point included hemolysis, bleeding, and AKI requiring RRT. Results: Three studies met the inclusion criteria. The use of Impella as an unloading device in patients with cardiogenic shock on VA-ECMO was associated with increasing the risk of hemolysis RR: 2.64, 95% CI (1.973.55) p= <0.01, neutral risk of bleeding RR: 1.11, 95% CI (0.77-1.60) p=0.58 and neutral risk of acute kidney injury requiring renal replacement therapy 1.35, 95% CI (0.95-1.91) p=0.10 when compare with patients. VA-ECMO plus Impella was associated with lower mortality RR: 0.76, 95% CI (0.62-0.94) p= 0.01 than VA-ECMO alone. Conclusion: This metanalysis suggests that the use of Impella as an unloading device in patients with cardiogenic shock in VA-ECMO has a higher risk of hemolysis, but an equal risk of bleeding and AKI requiring RRT than patients treated with VA-ECMO alone.
409
Creatinine Blood Urea Nitrogen (BUN) Lactic acid Alanine aminotransferase (ALT) Aspartate aminotransferase (AST)
Pre VA-ECMO
Pre MCS
P Value
1.9§0.9 27§9 5.3§3.6 491§784
1§0.3 25§11 0.9§0.3 35§15
<0.05 0.7 <0.05 0.15
491§784
30§11
0.054
(continued)
Lactate Predicts Mortality 12 Hours after VA ECMO Initiation A. Melvin, B.C. Ayers, K. Wood, S. Prasad, B. Barrus and I. Gosev. University of Rochester, Rochester, NY. Purpose: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an important but resource intensive therapy for refractory cardiogenic shock. We aimed to identify the utility of early elevated lactate levels as a predictor of ECMO mortality. Methods: We retrospectively reviewed patients supported by VA-ECMO from 2011-2018 (N=247). Patients were grouped into a mortality cohort
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
patients developed refractory LV distention with pulmonary edema despite maximum medical treatment and required either atrial septostomy or additional mechanical support. Minimum PCWP readings during pVA-ECMO were 12.8 mmHg (11.0-14.4) in patients without and 10.0 mmHg (8.017.0) in patients with need for dMCS (p=0.236). Minimum LVSWT during pVA-ECMO were 2.7 £ 105 dynes/cm (2.0-3.5) in patients without and 3.5 £ 105 dynes/cm (3.1-4.0) in patients with need for dMCS (p=0.002). Adjusting for age and race in a logistic regression model revealed that only post-cardiotomy pVA-ECMO and LVSWT, but not minimum PCWP were independently associated with need for dMCS after pVA-ECMO. Conclusion: We show that strict medical management can lead to LV unloading, i.e. minimum PCWP < 18 mmHg, in the vast majority of patients requiring pVA-ECMO for advanced cardiogenic shock. However, high LVSWT during pVA-ECMO remained predictive of need for dMCS even with unloaded LV.
407 Bridging VA ECMO to Durable MCS: Keys to Success A.M. El Banayosy, M.M. Koerner, D.A. Horstmanshof, A. Phancao, B.V. Jassman, C. Elkins, J.W. Long and A. El Banayosy. INTEGRIS Baptist Medical Center, Oklahoma City, OK. Purpose: There is limited data in the literature defining criteria for bridging advanced cardiogenic shock (ACS) patients supported by veno-arterial (VA) ECMO to durable Mechanical Circulatory Support (MCS). We evaluated our screening process on outcomes for all patients at our center bridged from VA ECMO to durable MCS. Methods: From September 2014 to October 2018, 153 patients received VA ECMO for treatment of ACS greater than 24 hours. Care was withdrawn from 64 (42%) patients, 68 (44%) were successfully weaned from VA ECMO, 4 (3%) were bridged to extracorporeal biventricular assist device, and 14 (9%) were bridged to durable MCS, which were included in this retrospective analysis. All 14 patients accepted for durable support implantation underwent a multidisciplinary screening process. Criteria for candidacy included 1) acceptable end organ function, 2) extubation, 3) negative infection surveillance, and 4) neurologically intact. To compare clinical status pre VA ECMO and pre MCS, end organ function was assessed by Sequential Organ Failure Assessment (SOFA) score, lactic acid, renal, and hepatic markers. Outcomes assessed included survival and post durable MCS implant hospital length of stay (HLOS). Results: As of October 2018, 11 of the 14 patients bridged to durable MCS are still alive (79%). Mean duration of support on VA ECMO before transition was 11 days § 5 (4-22), and a mean of 343 days § 312 (28-1041) on durable MCS. The mean post MCS HLOS was 29 days § 20 (9-90). Of the 14 patients, 11 were transitioned to LVAD. One patient was explanted due to cardiac recovery, 1 received a heart transplant, 1 deceased, and 8 are still on LVAD support. In 2 patients, temporary RVAD support was required post LVAD. Three of the 14 were bridged to Total Artificial Heart, of which 2 have died. Conclusion: Applying a thorough screening process to INTERMACS level 1 patients bridged with VA ECMO to durable MCS is a highly successful strategy and yields excellent long-term survival. Our screening process might be a useful guide to bridge select VA ECMO patients to cardiac transplantation.
(Continued)
White blood cell count Platelet count SOFA Inotropes ≥1 Mechanical ventilation Age Sex
Pre VA-ECMO
Pre MCS
P Value
18§10 227§116 11§2 14 (100%) 14 (100%) 55§15 (21-73) Male: 12, Female: 3
11§5 122§72 7§3 4 (28.6%) 1 (7.1%)
<0.05 <0.05 <0.05 n/a n/a
408 Hematological Complications of Impella as an Unloading Device in Patients with Cardiogenic Shock and Veno-Arterial ECMO. A Systematic Review and Metanalysis J.E. Pino,1 E. Grajeda,1 F. Ramos-Tuarez,1 S. Sundaravel,1 S. Sehatbakhsh,2 E. Donath,1 and R. Chait.2 1Medicine, University of Miami/ JFK Medical Center, West Palm Beach, FL; and the 2Medicine, University of Miami/ JFK Medical Center, Atlantis, FL. Purpose: Veno-arterial extracorporeal membrane oxygenation (VAECMO) is commonly used in patients with severe cardiogenic shock. However, left ventricular unloading may be impaired due to an increase in afterload caused by VA-ECMO. Impella has surged as an unloading device in this scenario but, its concomitant use with VAECMO has been associated with a higher risk of bleeding, hemolysis and acute kidney injury (AKI) requiring renal replacement therapy (RRT) in these patients. Methods: This is a metanalysis and systematic review that aimed to evaluate the hematological complications of the concomitant use of Impella and VA-ECMO in patients with cardiogenic shock. Pubmed, Cochrane and Scopus data based were used. Primary end-point included hemolysis, bleeding, and AKI requiring RRT. Results: Three studies met the inclusion criteria. The use of Impella as an unloading device in patients with cardiogenic shock on VA-ECMO was associated with increasing the risk of hemolysis RR: 2.64, 95% CI (1.973.55) p= <0.01, neutral risk of bleeding RR: 1.11, 95% CI (0.77-1.60) p=0.58 and neutral risk of acute kidney injury requiring renal replacement therapy 1.35, 95% CI (0.95-1.91) p=0.10 when compare with patients. VA-ECMO plus Impella was associated with lower mortality RR: 0.76, 95% CI (0.62-0.94) p= 0.01 than VA-ECMO alone. Conclusion: This metanalysis suggests that the use of Impella as an unloading device in patients with cardiogenic shock in VA-ECMO has a higher risk of hemolysis, but an equal risk of bleeding and AKI requiring RRT than patients treated with VA-ECMO alone.
409
Creatinine Blood Urea Nitrogen (BUN) Lactic acid Alanine aminotransferase (ALT) Aspartate aminotransferase (AST)
Pre VA-ECMO
Pre MCS
P Value
1.9§0.9 27§9 5.3§3.6 491§784
1§0.3 25§11 0.9§0.3 35§15
<0.05 0.7 <0.05 0.15
491§784
30§11
0.054
(continued)
Lactate Predicts Mortality 12 Hours after VA ECMO Initiation A. Melvin, B.C. Ayers, K. Wood, S. Prasad, B. Barrus and I. Gosev. University of Rochester, Rochester, NY. Purpose: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an important but resource intensive therapy for refractory cardiogenic shock. We aimed to identify the utility of early elevated lactate levels as a predictor of ECMO mortality. Methods: We retrospectively reviewed patients supported by VA-ECMO from 2011-2018 (N=247). Patients were grouped into a mortality cohort