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Massive Pulmonary EmbolismPercutaenousECMORVAD

Eric M Gnall DO FACC

Director of ECMOAcute Mechanical Circulatory Support Main Line Health Lankenau Medical Center

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

DuringAfter Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Mean survival for extracorporeal cardiopulmonary

resuscitation patients after 6ndash20 20ndash45 45ndash60 and 60ndash

135 minutes of mechanical cardiopulmonary resuscitation

(CPR) ( pthinsp=thinsp0001) Wengenmayer et al Critical Care201721157

CPR Duration vs SurvivalRetrospective registry data on all patients with eCPR including PE

ECPR registry data showing average times to execute ECMObull Duration of mechanical CPR until VA-ECMO support

bull OHCA 722thinspplusmnthinsp74 minutes

bull IHCA patients 496 plusmnthinsp59 vs

bull Notification at time zero(ECMO team part of PERT)

bull Deployment systembull Team Members pre specified duties

bull Practice Drills to maintain efficiency

Timing of Mechanical Support

Survival

Prior to CPR After CPR After CPR 30 mins

7627

10

1 George B et al A retrospective comparison of survivors and non- survivors of massive pulmonary embolism receiving VA ECMO support Resuscitation 2018 12212 Yusuff HO A Extracorporeal membrane oxygenation in acute massive pulmonary embolism a systematic review Perfusion 201530611

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

After Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Massive PE

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

DuringAfter Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Mean survival for extracorporeal cardiopulmonary

resuscitation patients after 6ndash20 20ndash45 45ndash60 and 60ndash

135 minutes of mechanical cardiopulmonary resuscitation

(CPR) ( pthinsp=thinsp0001) Wengenmayer et al Critical Care201721157

CPR Duration vs SurvivalRetrospective registry data on all patients with eCPR including PE

ECPR registry data showing average times to execute ECMObull Duration of mechanical CPR until VA-ECMO support

bull OHCA 722thinspplusmnthinsp74 minutes

bull IHCA patients 496 plusmnthinsp59 vs

bull Notification at time zero(ECMO team part of PERT)

bull Deployment systembull Team Members pre specified duties

bull Practice Drills to maintain efficiency

Timing of Mechanical Support

Survival

Prior to CPR After CPR After CPR 30 mins

7627

10

1 George B et al A retrospective comparison of survivors and non- survivors of massive pulmonary embolism receiving VA ECMO support Resuscitation 2018 12212 Yusuff HO A Extracorporeal membrane oxygenation in acute massive pulmonary embolism a systematic review Perfusion 201530611

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

After Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Massive PE

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

Mean survival for extracorporeal cardiopulmonary

resuscitation patients after 6ndash20 20ndash45 45ndash60 and 60ndash

135 minutes of mechanical cardiopulmonary resuscitation

(CPR) ( pthinsp=thinsp0001) Wengenmayer et al Critical Care201721157

CPR Duration vs SurvivalRetrospective registry data on all patients with eCPR including PE

ECPR registry data showing average times to execute ECMObull Duration of mechanical CPR until VA-ECMO support

bull OHCA 722thinspplusmnthinsp74 minutes

bull IHCA patients 496 plusmnthinsp59 vs

bull Notification at time zero(ECMO team part of PERT)

bull Deployment systembull Team Members pre specified duties

bull Practice Drills to maintain efficiency

Timing of Mechanical Support

Survival

Prior to CPR After CPR After CPR 30 mins

7627

10

1 George B et al A retrospective comparison of survivors and non- survivors of massive pulmonary embolism receiving VA ECMO support Resuscitation 2018 12212 Yusuff HO A Extracorporeal membrane oxygenation in acute massive pulmonary embolism a systematic review Perfusion 201530611

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

After Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Massive PE

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

ECPR registry data showing average times to execute ECMObull Duration of mechanical CPR until VA-ECMO support

bull OHCA 722thinspplusmnthinsp74 minutes

bull IHCA patients 496 plusmnthinsp59 vs

bull Notification at time zero(ECMO team part of PERT)

bull Deployment systembull Team Members pre specified duties

bull Practice Drills to maintain efficiency

Timing of Mechanical Support

Survival

Prior to CPR After CPR After CPR 30 mins

7627

10

1 George B et al A retrospective comparison of survivors and non- survivors of massive pulmonary embolism receiving VA ECMO support Resuscitation 2018 12212 Yusuff HO A Extracorporeal membrane oxygenation in acute massive pulmonary embolism a systematic review Perfusion 201530611

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

After Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Massive PE

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

Timing of Mechanical Support

Survival

Prior to CPR After CPR After CPR 30 mins

7627

10

1 George B et al A retrospective comparison of survivors and non- survivors of massive pulmonary embolism receiving VA ECMO support Resuscitation 2018 12212 Yusuff HO A Extracorporeal membrane oxygenation in acute massive pulmonary embolism a systematic review Perfusion 201530611

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

After Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Massive PE

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

ECMO Stand-by

Mechanical Support

After Cardiac

Arrest

Mechanical Support

Prior to Cardiac

Arrest

VA

VA RPProteck

Systemic

Thrombolytics

Circ 2004 8110 Metaanalysis of thrombolytics in PE

Massive PE

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

Massive PE

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

Massive PE

bull ECHO RV dysfunction without hemodynamics is a weak predictor of mortality and alone cannot support Mechanical Support Initiation Cardiol Res 2017

Aug 8(4) 143ndash146

bull CT BurdenObstruction Index alone cannot support Mechanical Support Initiationbull Does not predict mortality over vitals in this populationbull (1 Subramaniam et all AJR2008 2 Hadil et al 2014 3 HUISMAN RADIOLOGY 2005 )

Hemodyanmics + ECHORegistry 1000 PEkasper et al JACC 1997

In Hospital Mortality

0

10

20

30

40

50

60

70

Mcconnelsign

Hypotension5 Dobut

HypotensionShock gt 5

Dobutamine

CPR

mortality

Factors favoring MCS

1 Escalating Vasopressor requirements

2 Requiring intubation

Hemodynamic Collapse with Intubationbull Rosenberger et al - Fifty-two consecutive patients

undergoing emergent pulmonary embolectomybull 19 cardiac arrestbull 17 severe decompensationbull Overall mortality 25 Can J Anaesth 2007 Aug54(8)634-41

bull Mechanism1 Sedation lowering SVR2 Positive pressure ventilation increasing RV afterload

Rosenberger PS et al Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy Anesth Analg 20061021311Bennett JM et al Hemodynamic instability in patients undergoing pulmonaryembolectomy institutional experience Journal of Clinical Anesthesia (2015) 27207 213

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

Factors favoring MCS

bull Lactate Prior to CPR thinsple6mmolL

bull 824 sensitivity and 846 specificity for predicting survival to discharge George B et al A retrospective comparison of survivors and non survivors of massive pulmonary embolism receiving VA ECMO sup port Resuscitation 2018 1221 retro n=32

bull Also catheter directed gt Systemic survival

bull DrsquoArrigoa et al resuscitation201710005 retro n = 17

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

Thrombus in Transit Predicts Higher Mortalitybull Visualization of Thrombus on Echo in Right Heart is

a predictor of increased mortalitybull Mortality rate with no therapy 100

bull Mortality rate with heparin 30

bull Mortality rate with Embolectomy 23

bull Mortality with thrombolysis 11

bull Rose et al Chest 2002

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

Factors favoring MCS

1 Escalating Vasopressor requirements

2 Requiring intubation

Hemodynamic Collapse with Intubationbull Rosenberger et al - Fifty-two consecutive patients

undergoing emergent pulmonary embolectomybull 19 cardiac arrestbull 17 severe decompensationbull Overall mortality 25 Can J Anaesth 2007 Aug54(8)634-41

bull Mechanism1 Sedation lowering SVR2 Positive pressure ventilation increasing RV afterload

Rosenberger PS et al Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy Anesth Analg 20061021311Bennett JM et al Hemodynamic instability in patients undergoing pulmonaryembolectomy institutional experience Journal of Clinical Anesthesia (2015) 27207 213

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

Factors favoring MCS

bull Lactate Prior to CPR thinsple6mmolL

bull 824 sensitivity and 846 specificity for predicting survival to discharge George B et al A retrospective comparison of survivors and non survivors of massive pulmonary embolism receiving VA ECMO sup port Resuscitation 2018 1221 retro n=32

bull Also catheter directed gt Systemic survival

bull DrsquoArrigoa et al resuscitation201710005 retro n = 17

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

Thrombus in Transit Predicts Higher Mortalitybull Visualization of Thrombus on Echo in Right Heart is

a predictor of increased mortalitybull Mortality rate with no therapy 100

bull Mortality rate with heparin 30

bull Mortality rate with Embolectomy 23

bull Mortality with thrombolysis 11

bull Rose et al Chest 2002

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

Hemodynamic Collapse with Intubationbull Rosenberger et al - Fifty-two consecutive patients

undergoing emergent pulmonary embolectomybull 19 cardiac arrestbull 17 severe decompensationbull Overall mortality 25 Can J Anaesth 2007 Aug54(8)634-41

bull Mechanism1 Sedation lowering SVR2 Positive pressure ventilation increasing RV afterload

Rosenberger PS et al Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy Anesth Analg 20061021311Bennett JM et al Hemodynamic instability in patients undergoing pulmonaryembolectomy institutional experience Journal of Clinical Anesthesia (2015) 27207 213

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

Factors favoring MCS

bull Lactate Prior to CPR thinsple6mmolL

bull 824 sensitivity and 846 specificity for predicting survival to discharge George B et al A retrospective comparison of survivors and non survivors of massive pulmonary embolism receiving VA ECMO sup port Resuscitation 2018 1221 retro n=32

bull Also catheter directed gt Systemic survival

bull DrsquoArrigoa et al resuscitation201710005 retro n = 17

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

Thrombus in Transit Predicts Higher Mortalitybull Visualization of Thrombus on Echo in Right Heart is

a predictor of increased mortalitybull Mortality rate with no therapy 100

bull Mortality rate with heparin 30

bull Mortality rate with Embolectomy 23

bull Mortality with thrombolysis 11

bull Rose et al Chest 2002

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

Factors favoring MCS

bull Lactate Prior to CPR thinsple6mmolL

bull 824 sensitivity and 846 specificity for predicting survival to discharge George B et al A retrospective comparison of survivors and non survivors of massive pulmonary embolism receiving VA ECMO sup port Resuscitation 2018 1221 retro n=32

bull Also catheter directed gt Systemic survival

bull DrsquoArrigoa et al resuscitation201710005 retro n = 17

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

Thrombus in Transit Predicts Higher Mortalitybull Visualization of Thrombus on Echo in Right Heart is

a predictor of increased mortalitybull Mortality rate with no therapy 100

bull Mortality rate with heparin 30

bull Mortality rate with Embolectomy 23

bull Mortality with thrombolysis 11

bull Rose et al Chest 2002

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

Factors favoring MCS

bull Lactate Prior to CPR thinsple6mmolL

bull 824 sensitivity and 846 specificity for predicting survival to discharge George B et al A retrospective comparison of survivors and non survivors of massive pulmonary embolism receiving VA ECMO sup port Resuscitation 2018 1221 retro n=32

bull Also catheter directed gt Systemic survival

bull DrsquoArrigoa et al resuscitation201710005 retro n = 17

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

Thrombus in Transit Predicts Higher Mortalitybull Visualization of Thrombus on Echo in Right Heart is

a predictor of increased mortalitybull Mortality rate with no therapy 100

bull Mortality rate with heparin 30

bull Mortality rate with Embolectomy 23

bull Mortality with thrombolysis 11

bull Rose et al Chest 2002

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

Thrombus in Transit Predicts Higher Mortalitybull Visualization of Thrombus on Echo in Right Heart is

a predictor of increased mortalitybull Mortality rate with no therapy 100

bull Mortality rate with heparin 30

bull Mortality rate with Embolectomy 23

bull Mortality with thrombolysis 11

bull Rose et al Chest 2002

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

Thrombus in Transit Predicts Higher Mortalitybull Visualization of Thrombus on Echo in Right Heart is

a predictor of increased mortalitybull Mortality rate with no therapy 100

bull Mortality rate with heparin 30

bull Mortality rate with Embolectomy 23

bull Mortality with thrombolysis 11

bull Rose et al Chest 2002

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

Factors favoring MCS

1 Vasopressor requirements

2 Requiring intubation

3 Serum Lactate

4 Thrombus in Transit

5 Shock despite Lytics

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

J Trauma 2007 Mar62(3)570-6Extracorporeal life support for massive pulmonary embolismMaggio P1 Hemmila M Haft J Bartlett R University of Michigen

bull N = 21 of 43 screened

bull 45 survival in the cohort when ECMO followed other therapies

bull 80 survival when ECMO initiation occurred before other therapies

VA ECMO

Chetan Pasrija et al Utilization of Veno-Arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism Annals of Thoracic Surgery Feb 2018 Univ Maryland

Only 1 patient was not alive at 90days50 resolved on anticoagulation aloneNo patients died after surgical embolectomy

Prior to ECMO 5 ndash CPR7- Systemic Lytics

Protocol

bull A 6F distal perfusion line was placed in the superficial femoral artery first if able unless the patient was actively requiring cardiopulmonary resuscitation (CPR)

bull Pre-close or Post-Close is possible with both 17 and 19 Fr cannula

bull In non-intubated patients moderate sedation with 05 mgkg ketamine and local anesthetic agent with 20 to 30 mL of 2 lidocaine was used before cannulation

PREDICTORS OF RIGHT VENTRICULAR RECOVERY IN PATIENTS SUPPORTED WITH VA-ECMO FOR ACUTE MASSIVE PULMONARY EMBOLISMArticle JACC March 2018Mar 2018Journal of the American College of Cardiology

bull Same Cohort but N = 30

bull 53 responded to AC alone

bull 47 required embolectomy

Protocol

bull A 6F distal perfusion line was placed in the superficial femoral artery first if able unless the patient was actively requiring cardiopulmonary resuscitation (CPR)

bull Pre-close or Post-Close is possible with both 17 and 19 Fr cannula

bull In non-intubated patients moderate sedation with 05 mgkg ketamine and local anesthetic agent with 20 to 30 mL of 2 lidocaine was used before cannulation

PREDICTORS OF RIGHT VENTRICULAR RECOVERY IN PATIENTS SUPPORTED WITH VA-ECMO FOR ACUTE MASSIVE PULMONARY EMBOLISMArticle JACC March 2018Mar 2018Journal of the American College of Cardiology

bull Same Cohort but N = 30

bull 53 responded to AC alone

bull 47 required embolectomy

PREDICTORS OF RIGHT VENTRICULAR RECOVERY IN PATIENTS SUPPORTED WITH VA-ECMO FOR ACUTE MASSIVE PULMONARY EMBOLISMArticle JACC March 2018Mar 2018Journal of the American College of Cardiology

bull Same Cohort but N = 30

bull 53 responded to AC alone

bull 47 required embolectomy

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

Mechanical Support Stand-by

High Risk Signs

VA risk and AccessNo High Risk Signs

VA RPDuo

1 Vasopressor requirements2 Requiring intubation3 Serum Lactate4 Thrombus in Transit

VA ECMO

for Cardiac Arrest

With or without ROSC

Perc RVAD

Impella RPCase Series

bull 5 patient Case series from Detroit Medical Center with 100 survival J Interv Cardiol 2018 Aug31(4)518-524

bull 2 Cases Texas Heart impella plus Ekos Tex Heart Inst J 2018 Jun 145(3)182-185

Perc RVAD

Impella RPCase Series

bull 5 patient Case series from Detroit Medical Center with 100 survival J Interv Cardiol 2018 Aug31(4)518-524

bull 2 Cases Texas Heart impella plus Ekos Tex Heart Inst J 2018 Jun 145(3)182-185

Impella RPCase Series

bull 5 patient Case series from Detroit Medical Center with 100 survival J Interv Cardiol 2018 Aug31(4)518-524

bull 2 Cases Texas Heart impella plus Ekos Tex Heart Inst J 2018 Jun 145(3)182-185

Perc RVAD

Impella RP

bull Xray

bull No intubation

bull Intracorporeal

bull Thrombus Sensitive

Proteck DUO

bull Xray C-arm

bull No intubation

bull Extracorporeal

bull Thrombus Forgiving

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

Mechanical Support Stand-by

High Risk Signs

VA risk and AccessNo High Risk Signs

VA RPDuo

1 High Vasopressor requirements2 Requiring intubation3 Serum Lactate4 Thrombus in Transit

VA ECMO

for Cardiac Arrest

With or without ROSC

Massive Pulmonary Embolism with Hemodynamic Compromise

Massive Pulmonary

Embolism

Saftey Lines

Mechanical Support Stand-by

High Risk Signs

VA risk and AccessNo High Risk Signs

VA RPDuo

1 High Vasopressor requirements2 Requiring intubation3 Serum Lactate4 Thrombus in Transit

VA ECMO

for Cardiac Arrest

With or without ROSC