Outcomes of ECMO

Pramod Bonde

Travel…

What is ECMO?

Take blood from right atrium (V)

&

return beyond aortic valve (A)

Vein—oxygenate--Vein

Long shunt with large bore at one end and small at other with a pump and

oxygenator in between

Tool not therapy!

Who?

Patients with life-threatening hypotension despite rapidly escalating inotropic support, critical organ hypoperfusion, often confirmed by worsening acidosis and/or lactate levels &/or inability to oxygenate due to cardiac failure…..

So what do you do when faced with it?

How do I view it?

A momentary pause in the act of deathJohn Warren, 1800s

Scenarios

• Cath lab crashes• Acute MI----cardiogenic shock• Acute decompensation of CHF• Post cardiotomy• Post heart transplant: PGD• EPCR

Pulmonary

• ARDS• ALI• Viral Pneumonia• H1N1• Non ARDS acute respiratory failure

Why ECMO mortality high?

Because current indications

Heroic

Altruistic

Realistic

Constructive

In spite of that….

ELSO Registry Data Summary

July 2018

60

40

30

Overall Patient Outcomes

ELSO Registry July 2018

Total Runs Survived ECLS Survived to DCNeonatalPulmonary 30,934 25,990 84% 22,662 73%Cardiac 7,794 5,063 64% 3,281 42%ECPR 1,718 1,140 66% 708 41%PediatricPulmonary 8,820 5,953 67% 5,131 58%Cardiac 10,462 7,177 68% 5,447 52%ECPR 3,946 2,262 57% 1,675 42%AdultPulmonary 16,337 10,857 66% 9,649 59%Cardiac 15,942 8,865 55% 6,747 42%ECPR 4,952 1,896 38% 1443 29% Total 100,905 69,203 68% 56,743 56%

2_OverallPatientOutcomes_201701

Total RunsSurvived ECLSSurvived to DC

Neonatal

Pulmonary30,93425,99084%22,66273%

Cardiac7,7945,06364%3,28142%

ECPR1,7181,14066%70841%

Pediatric

Pulmonary8,8205,95367%5,13158%

Cardiac10,4627,17768%5,44752%

ECPR3,9462,26257%1,67542%

Adult

Pulmonary16,33710,85766%9,64959%

Cardiac15,9428,86555%6,74742%

ECPR4,9521,89638%144329%

Total100,90569,20368%56,74356%

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

0

500

1000

1500

2000

2500

3000

3500

Annual Runs Cumulative Runs

Adult Respiratory CasesAn

nual

Run

s

Cumulative Runs

ELSO Registry July 2018

Adult Cases by Diagnosis since 2013

0500

10001500200025003000350040004500

Viralpneumonia

Bacterialpneumonia

Aspirationpneumonia

ARDS Acute respfailure, non-

ARDS

Other

Died 258 367 45 517 684 2380Surv 478 609 104 906 1003 3539

Tota

l Run

s

62%64%

69%

63%

59%

59%

ELSO Registry July 2018

Adult Survival by Diagnosis and Year

0%

20%

40%

60%

80%

100%

120%

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Viral Pneum

Bact Pneum

Aspir Pneum

ARDS

ARF non ARDS

Other

ELSO Registry July 2018

Adult Cardiac Cases By Year

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

0

500

1000

1500

2000

2500

3000

3500

4000

Annual Runs Cumulative Runs

Annu

al R

uns

Cumulative Runs

ELSO Registry July 2018

Cardiac ECLS by Diagnosis Adult since 2013

0

1000

2000

3000

4000

5000

CongenitalDefect

CardiacArrest

CardiogenicShock

Cardiomyopathy

Myocarditis Other

Died 138 245 1705 180 53 3894Surv 88 125 1312 198 80 3030

Tota

l Run

s

33%38%

43%

52% 60%

43%

ELSO Registry July 2018

Adult ECPR Cases

0

1000

2000

3000

4000

5000

6000

0

200

400

600

800

1000

1200

Annual Runs Cumulative Runs

Annu

al R

uns

Cumulative Runs

ELSO Registry July 2018

Indications..

• Cardiac index < 1.8• Wedge > 20• CVP > 20• Systemic BP < 80• Maxed out ventilation (PEEP>20, FIO2-100,

Max RR)

Caveat….surrogate

Frequently you have none of these numbers

Is it too late to institute

Difficulties

Delayed referralCardiac arrest/unknown neurological status

Frequently ventilatedNot very tolerant of inotropes

Organ dysfunctionAnticoagulants onboard

What should we do….

Typical management response…

Sauer CM, Yuh DD, Bonde P. Extracorporeal membrane oxygenation use hasincreased by 433% in adults in the United States from 2006 to 2011. ASAIO J.

2015 Jan-Feb;61(1):31-6.

Sauer CM, Yuh DD, Bonde P. Extracorporeal membrane oxygenation use hasincreased by 433% in adults in the United States from 2006 to 2011. ASAIO J.

2015 Jan-Feb;61(1):31-6.

Can we improve the outcome?

Management philosophy…

Stretch R et al. J Am Coll Cardiol. 2014 Oct 7;64(14):1407-15.

Use of temporary cardiac support devices has increased

Bonde et al, JACC, Nov, 2014

Thiagarajan RR et al. ASAIO J. 2017 Jan/Feb;63(1):60-67.

Stretch R et al. J Am Coll Cardiol. 2014 Oct 7;64(14):1407-15.

But CPR can save lives in cardiac arrest…..

CPR

CPR

CPR

CPR

Romantic therapy with no actual effect….

Ohh…but they are destined to die....

Not true…..

Overall Patient Outcomes

ELSO Registry July 2018

Total Runs Survived ECLS Survived to DCNeonatalPulmonary 30,934 25,990 84% 22,662 73%Cardiac 7,794 5,063 64% 3,281 42%ECPR 1,718 1,140 66% 708 41%PediatricPulmonary 8,820 5,953 67% 5,131 58%Cardiac 10,462 7,177 68% 5,447 52%ECPR 3,946 2,262 57% 1,675 42%AdultPulmonary 16,337 10,857 66% 9,649 59%Cardiac 15,942 8,865 55% 6,747 42%ECPR 4,952 1,896 38% 1443 29% Total 100,905 69,203 68% 56,743 56%

2_OverallPatientOutcomes_201701

Total RunsSurvived ECLSSurvived to DC

Neonatal

Pulmonary30,93425,99084%22,66273%

Cardiac7,7945,06364%3,28142%

ECPR1,7181,14066%70841%

Pediatric

Pulmonary8,8205,95367%5,13158%

Cardiac10,4627,17768%5,44752%

ECPR3,9462,26257%1,67542%

Adult

Pulmonary16,33710,85766%9,64959%

Cardiac15,9428,86555%6,74742%

ECPR4,9521,89638%144329%

Total100,90569,20368%56,74356%

Bitter truths….

ECMO

Even Corpses Maintain Oxygenation

Beware……

Outcomes directly proportional to surgeon investment….

Devices are getting better…..

Incremental progress can be good….

But incremental innovation has its price….

It is not guaranteed forever..

Destination should be in mind before starting ECMO …..

Adult strategy is not same as neonatal or pediatric

P ≠ C ≠ E

Technique vs Tardiness

Revenue vs Reason

Value vs Virtue

Tool not therapy

Innovation is the key….

Modified SurfacesBaseline Surface

Engineered Super-Slippery Surface

Breaking the Time Barrier of Drop Bouncing

J. C. Bird, R. Dhiman, H-M. Kwon, K. K. Varanasi, Nature 2013

Super non-thrombotic surface

Lets see what you will do….

A 82 years old wife of former hospital CEO on five maxed out

inotropes/pressors, BP: 60, baseline EF: 10%, creatinine 4, BMI of 40, coded

for 120 minutes

Please call the priest!

Thank you….

Outcomes of ECMOTravel…Slide Number 3What is ECMO?Take blood from right atrium (V) ��&� �return beyond aortic valve (A)Vein—oxygenate--VeinLong shunt with large bore at one end and small at other with a pump and oxygenator in between��Tool not therapy!Who?Slide Number 9So what do you do when faced with it?Slide Number 11How do I view it?Slide Number 13ScenariosPulmonaryWhy ECMO mortality high?Because current indicationsIn spite of that….ELSO Registry Data Summary60��40��30Overall Patient OutcomesSlide Number 22Slide Number 23Adult Survival by Diagnosis and YearSlide Number 25Slide Number 26Slide Number 27Indications..Caveat….surrogateIs it too late to instituteDifficultiesWhat should we do….Typical management response…Sauer CM, Yuh DD, Bonde P. Extracorporeal membrane oxygenation use has�increased by 433% in adults in the United States from 2006 to 2011. ASAIO J. 2015 Jan-Feb;61(1):31-6.Sauer CM, Yuh DD, Bonde P. Extracorporeal membrane oxygenation use has�increased by 433% in adults in the United States from 2006 to 2011. ASAIO J. 2015 Jan-Feb;61(1):31-6.Can we improve the outcome?Management philosophy…Slide Number 38Bonde et al, JACC, Nov, 2014Slide Number 40Slide Number 41But CPR can save lives in cardiac arrest…..CPRCPRCPRCPRRomantic therapy with no actual effect….Ohh…but they are destined to die....Not true…..Overall Patient OutcomesBitter truths….ECMO��Even Corpses Maintain OxygenationBeware……Slide Number 54Outcomes directly proportional to surgeon investment….Devices are getting better…..Incremental progress can be good….But incremental innovation has its price….It is not guaranteed forever..Destination should be in mind before starting ECMO …..Adult strategy is not same as neonatal or pediatric P ≠ C ≠ ETechnique vs TardinessRevenue vs ReasonValue vs VirtueTool not therapyInnovation is the key….Modified SurfacesBreaking the Time Barrier of Drop BouncingSuper non-thrombotic surfaceLets see what you will do….A 82 years old wife of former hospital CEO on five maxed out inotropes/pressors, BP: 60, baseline EF: 10%, creatinine 4, BMI of 40, coded for 120 minutesPlease call the priest!Thank you….