acute heart failure : ecmo from jewbali - november 2012 · 5/19/2012 · case ddd-icd implanted...
TRANSCRIPT
![Page 1: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/1.jpg)
Acute heart failure: ECMOCardiology & Vascular Medicine 2012
Lucia Jewbali
cardiologist-intensivist
![Page 2: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/2.jpg)
![Page 3: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/3.jpg)
� 14 beds/8 ICU beds
� Acute coronary syndromes
� Heart failure/ Cardiogenic� Heart failure/ Cardiogenic
shock
� Post cardiotomy
� Heart transplantation
� IABP/ECMO/LVAD
� Post-procedure observation
percutananeous valves
![Page 4: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/4.jpg)
ECMO
Extra Corporeal Membrane Oxygenation
![Page 5: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/5.jpg)
Q 1 : ECMO (extracorporeal membrane oxygenation)
1. ECMO is available in my center and I have clinical experience with
managing ECMO patients
2. ECMO is available in my center but I am not directly involved in the
program
3. I have heard about ECMO; I am not familiar with this therapy and its
clinical applicability
![Page 6: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/6.jpg)
Case
� Female 59 years old
� No medical history
� Referred from regional hospital with sub-acute myocardial infarction
complicated by cardiogenic shock and third-degree AV block
![Page 7: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/7.jpg)
ECG
![Page 8: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/8.jpg)
Case
� PCI left anterior descending artery: trombus aspiration and stenting
(Promus DES 3.0x20 mm). RCA occluded with collateral flow from the
left anterior descending artery. Stenotic lesion ramus circumflexus
� Treated with temporary pacing lead, intra-aortic balloon pump and
high dose inotropics
� Transferred to ward after 1 week; ACE-inhibitor, diuretics and
eplenerone
![Page 9: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/9.jpg)
Case
� CK peak 5100 U/l, CK-MB peak 250 µg/l
� Weaned from IABP, inotropics and mechanical ventilation
� Echocardiography (TTE): Poor LV function
� Transferred to ward after 1 week; ACE-inhibitor, diuretics and
eplenerone
![Page 10: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/10.jpg)
Case
� DDD-ICD implanted
� Several shocks >> ventricular arrhythmias
� Medication:ACE-inhibitor, Eplenerone, beta-blocker, diuretics,
statines, ASA, prasugrel
![Page 11: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/11.jpg)
Reflections: what to do?
1. detection ischemia
2. increase dose beta blocker and/or add amiodarone
3. adjust ICD settings
![Page 12: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/12.jpg)
Case
� MIBI scan: large defect apex, septum, anterior- and inferior wall, no
ischemia
� FDG-PET scan: no hibernation myocard
� Increased beta blocker dosage
� Amiodarone added
� ICD settings adjusted
![Page 13: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/13.jpg)
Case
� Despite all this : electrical storm with hemodynamic instability
� Admitted into ICCU
� Amiodarone iv, Lidocaine iv, optimized electrolytes, anxiolytica,
vasopressor, inotropics
� Remained unstable �� eventually sedated, intubated and put on
mechanical ventilation
![Page 14: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/14.jpg)
Case
� Less arrhythmias, not event free
� Hypotensive (systolic blood pressure 90 mmHg) despite vasopressors� Hypotensive (systolic blood pressure 90 mmHg) despite vasopressors
and low dose inotropics
� Oliguria (< 35 mL/h), creatinin 144 µmol/L
� Signs of tissue hypoperfusion (cold peripheries)
� Lactate 1.7 mmol/l
![Page 15: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/15.jpg)
Q 2: what would be the next step?
1. Further adjustments of inotropics and anti-arrhytmics
2. place an intra-aortic balloon pump
3. no adjustments
![Page 16: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/16.jpg)
Case
- adjustments in medication did not improve hemodynamics
- intra-aortic balloonpump was placed
![Page 17: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/17.jpg)
Goal of treatment reached?
![Page 18: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/18.jpg)
Q 4 : What do the guidelines say?
Which are immediate goals of treatment in acute heart failure?
1. restore oxygenation, improve hemodynamics and organ perfusion
2. limit cardiac and renal damage2. limit cardiac and renal damage
3. prevent thrombo-emboli and minimize ICU length of stay
4. all of the above
![Page 19: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/19.jpg)
ESC guidelines acute and chronic heart failureEur Heart J. 2012 May 19
![Page 20: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/20.jpg)
How is the patient doing?
- Arrhythmias
- Sustained hypotension (systolic blood pressure < 90 mmHg) despite
vasopressors and low dose inotropics
- Oliguria (< 35 mL/h)
- Signs of tissue hypoperfusion (cold peripheries)
![Page 21: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/21.jpg)
Q 5: what do the guidelines say?
In patients remaining severely hypoperfused despite inotropic therapy and with a
potentially reversible cause short-term mechanical circulatory support:
1. is recommended (Class I)
2. should be considered (Class II a)2. should be considered (Class II a)
3. may be considered (Class II b)
4. is not recommended (Class III)
5. ECMO is not considered to be short-term mechanical support
![Page 22: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/22.jpg)
ESC guidelines acute and chronic heart failureEur Heart J. 2012 May 19
![Page 23: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/23.jpg)
Mechanical circulatory support
- intra-aortic ballonpump
- Ventricular assist devices
- percutaneous (Tandem Heart, Impella)
- surgical: LVAD, RVAD, BIVAD (Centrimag, Biomedicus, Medos,
Heartmate)
- ECMO
![Page 24: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/24.jpg)
� ECMO is a modification of the cardiopulmonary bypass circuit which is
used routinely in cardiac surgery
� It is used as temporary support, usually awaiting recovery of organs
![Page 25: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/25.jpg)
Dynamics of ECMO
![Page 26: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/26.jpg)
Indications for ECMO
� Divided into two type
� Cardiac Failure
� Respiratory Failure� Respiratory Failure
![Page 27: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/27.jpg)
Veno-arterial (VA) configuration
� Blood being drained from the venous system and returned to the
arterial system
� Provides both cardiac and respiratory support
� Achieved by either peripheral or central cannulation
![Page 28: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/28.jpg)
Central ECMO Cannulation
![Page 29: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/29.jpg)
![Page 30: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/30.jpg)
Peripheral ECMO Cannulation
![Page 31: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/31.jpg)
![Page 32: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/32.jpg)
![Page 33: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/33.jpg)
Things to Think About
� Mechanical ventilation must be continued during ECMO
support
� ECMO flow can be very volume dependent � ECMO flow can be very volume dependent
![Page 34: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/34.jpg)
Weaning of ECMO – VA ECMO
Depends on cardiac recovery
� Echo: improvement LV function
� Increasing blood pressure
� Return or increasing pulsatility on the arterial pressure waveform� Return or increasing pulsatility on the arterial pressure waveform
![Page 35: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/35.jpg)
Complications
Falls into one of three major categories
1) Bleeding/Hemolysis
2) Mechanical failure2) Mechanical failure
3) Neurologic events
![Page 36: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/36.jpg)
Decision to place ECMO
Several considerations must be weighed:
Likelihood of organ recovery
Advanced age
Malignancy
Graft vs. host disease
Known severe brain injury
Unwitnessed cardiac arrest or cardiac arrest of prolonged
duration.
![Page 37: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/37.jpg)
Q 5 : use of mechanical circulatory support
In this patient ECMO can be used as a:
1. bridge to decision
2. bridge to transplant2. bridge to transplant
3. bridge to recovery
4. destination therapy
![Page 38: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/38.jpg)
ESC guidelines acute and chronic heart failureEur Heart J. 2012 May 19
![Page 39: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/39.jpg)
INTERMACS profiles of advanced heart failure.
Stewart G C , Stevenson L W Circulation 2011;123:1559-1568
Copyright © American Heart Association
![Page 40: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/40.jpg)
Placement VA ECMO in cathlab
![Page 41: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/41.jpg)
Angio
![Page 42: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/42.jpg)
Case
Bridged to LVAD/ 4 days on ECMOBridged to LVAD/ 4 days on ECMO
Discharged from hospital twomonths after initial admittance
![Page 43: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/43.jpg)
Q 6 : survival following cardiac ECMO (adults) till hospital discharge
1. 54%
2. 44%
3. 34%
4. 24%
![Page 44: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/44.jpg)
![Page 45: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/45.jpg)
Cove and MacLaren Critical Care 2010, 14:235
![Page 46: Acute Heart failure : ECMO from Jewbali - November 2012 · 5/19/2012 · Case DDD-ICD implanted Several shocks >> ventricular arrhythmias Medication:ACE-inhibitor, Eplenerone, beta-blocker,](https://reader031.vdocuments.site/reader031/viewer/2022011910/5f7b8d2c6c323c4e4b4ef46d/html5/thumbnails/46.jpg)
Present clinical use of ECMO
� Post-cardiotomy
� Post-heart transplant
� Myocarditis
� PCI -assist
� Acute coronary syndrome with cardiogenic shock?
� Profound cardiac depression due to drug overdose or sepsis?