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Outcomes with ECMO for In Hospital Cardiac Arrest
Subhasis Chatterjee, MD, FACS, FACC, FCCP.
ECMO Program Director
CHI Baylor St. Lukes Medical Center/ Texas Heart Institute
Asst. Professor of Surgery, Baylor College of Medicine
American Association for Thoracic Surgery . Mechanical Circulatory Support SymposiumMarch 8, 2018. Houston, TX
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Disclosures• Nothing
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In Hospital Cardiac Arrest (IHCA)
•1. Outcomes of IHCA with Conventional CPR•2. Results of Outcomes of ECMO in IHCA•3. Prognostic Factors predicting success/failure
•4. Conduct of ECMO•5. Complications
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• 13 to 22% Survival to Hospital Discharge (STHD)
• 33% to 28% for significant neurologic disability
Girotra. NEJM 2012;367:1912-20.
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Uchenna R. Ofoma et al. JACC 2018;71:402-411
2018 American College of Cardiology Foundation
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IHCA: Public Perception of CPR
• Public perception: 75% watch medical dramas
• 57% believed an 80yo man with IHCA would survive with complete recovery. 1
• 72% believe that chance of full recovery after IHCA CPR is 75%. 2
2 Shif. Resuscitation 2015;90:73-78.1 Ouelette. Amer. Jrnl Emerg Med. 2018 IN PRESS
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Goldhaber ZD. Lancet 2012;380:1473-81.
-- 49% ROSC; 15% STHD-- + ROSC= 12 min (6-21) CPR- Hosp. in Longest quartile CPR 25” vs. 16” had higher ROSC (51 vs. 45%) & STHD (16 vs. 14%)
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What do the Guidelines Tell Us about Extracorporeal CPR (E-CPR)?
•Not Much
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Brooks SC. CIRCULATION 2015;132(18 Supp2):S436-43.
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Monsieurs KG. Resuscitation 2015;95:1-80
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ELSO ECPR
• E-CPR is defined as ECMO initiation during CPR without ROSC or in patients with transient ROSC
• Defines refractory CPR after 15”• Total Body Hypothermia should be
included– ice to head during CPR and for 48-72 hrs after cannulation
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Outcomes
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1976N=3541% survival
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ECPR outcomes in IHCAStudy, Country Design N Age (yrs)
Male (%)Time to ECLS (mts)
Neurologically Favorable Survival
Chen et al (2008)Taiwan
Prospective 59 18-75 <3030-4545-60>60
42%30%30%18%(33% Overall)
Lin et al (2010)Taiwan
Prospective 59 5985%
40 24%
Shin et al. (2011)Taiwan
Retrospective
85 6062%
42 28%
Chou et al. (2014)Taiwan
Retrospective
43 6193%
60 35%
Zhao et al. (2014)China
Retrospective
24 5979%
36 33%
Blumenstein et al (2016) Germany
Retrospective
52 7254%
33 21%
Chen. Lancet 2008;372:554-561. Lin. Resuscitation 2010;81:796-803. Shin. Crit Care Med. 2011;39:1-7. Chou. Emerg Med. Jrnl 2014;31:441-447. Zhao. Eur J Med Res. 2015;20:83. Blumenstein. Eur Hrt Jrnl. J Acute Cardiovasc Care 2016;5:13-22.
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Challenges in Interpreting the E-CPR Literature•1. What is E-CPR ? Is it cannulation during CPR vs. cannulation immediately after ROSC with ongoing CS ?
•2. Selection bias in E-CPR over C-CPR – felt to be “more salvageable”
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Outcomes: Meta-analyses
30-day survival for CA= 36% (23-50%) vs. CS= 53% (44-61%)
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- ECPR better survival (RR=2.37) and Neuro (2.79) than CCPR- ECPR no significant difference in IHCA but was in OHCA
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40% ECMO Survival30% STHD
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27% Survival
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IHCA Outcomes
• 3 year Prospective Observational Study
• Age 18-75• Witnessed IHCA and CPR>10”• ECMO (n=59) vs. Conv CPR
(n=113) Propensity matched
Chen YS. Lancet 2008;372:554-561.
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ECPR
CCPR
19% @ 1y29% @ 30d
12% @ 30d 10% @ 1y
Chen YS. Lancet 2008;372:554-561.
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Prognostic Factors
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Duration of CPR to Survival Discharge
Chen YS. Lancet 2008;372:554-561.
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Duration & Survival
<30” = 63% > 30” = 29%
<45” = 50% > 45” = 22%
<60” = 47% > 60” = 9%
Chen YS. Crit Care Med 2008;36:2529-35
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Age, CPR duration, Rhythm, ROSC
Lee SW. Ann Intensive Care 2017;7:87.
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Lactate < 4.6
88%
44%
HR 3.55 (2.29-5.49, p<0.001)
Jung. Clin Res Cardiol 2016;105:196-205
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Time to Coronary Intervention Matters
Chou TH. Emerg Med J 2014;31:441-47.
20%
40%
60%
80%
100%
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Who Should Not Have ECMO with IHCA
Patel JK. Jrnl Int Care Med 2016;31:359-68
Age<75VF/VT>>> OtherCPR start < 5-15”Cardiac/PE causeNo ROSC after 10-20”
Terminal illnessMajor comorbiditiesCNS Disease/ICHBleeding/AC ContraindSepsis ArrestAD/AI/PVD
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Conduct of E-CPR
Lee. Lancet 2008;372:512-4.
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Swol J. Perfusion 2016;31:182-88.
10-20”
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Cannulation• Who Should Cannulate ? Where ?
• Surgeons• Cardiologists• Intensivists• ER Physicians
• Tradeoff– Risk of Complications vs. Rapid Cannulation• Watch Out for Inadvertent Malposition i.e. VV or AA
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E-CPR Algorithm
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N=26 (15=IHCA, 11=OHCA)
92% had ECMO
Median 56”54% STHD
Mechanical CPRHypothermiaECMOEarly Reperfusion
Stub. Resuscitation 2015;86:88-94.
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Complications
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20 studies; 1866 patients
Cheng. Ann Thorac Surg 2014;97:610-6.
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17% LE Ischemia10% Fasciotomy5% Amputation
6% Stroke13% Neurologic
45-55% AKI/RRT40% Major Bleed/Takeback30% Infection
Cheng. Ann Thorac Surg 2014;97:610-6.
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ECMO Program Volume
0
20
40
60
80
100
120
140
2014 2015 2016 2017
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E-CPR Survival Rate
0
5
10
15
20
25
2016 2017
<7% Survival
Perc
ent S
urvi
val
Bloom HL. Am Heart J. 2007;153(5):831-6.
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ECMO Program Changes at Baylor St. Lukes/Texas Heart Institute
•Joined ELSO•Monthly Case Review Meetings•Routine Neurocritical Care Consultation•Routine Hematopathology Consultation (PTT, TEG, antiXa)
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E-CPR Survival Rate
0
5
10
15
20
25
2016 2017
Perc
ent S
urvi
val
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Conclusions
•20-30% STHD for IHCA•Witnessed arrest, rapid CPR, VT/VF, < 60” to ECMO
•Higher rate of complications