why would you do ecpr?

ECPR

Peter McCanny

……Rapid deployment of VA-ECMO during cardiac arrest, when conventional CPR has failed to provide return of spontaneous circulation (ROSC)……

……or when repetitive arrests occur without sustained ROSC……

ECMO for low output cardiac states

What is ECPR?

37yo massive PE post-op pelvic surgery

‘Temporary CPB provided 15mins of circulatory support while removal of bilateral pulmonary emboli was accomplished’

‘A battery- powered portable cardiopulmonary bypass machine has been used in 39 patients whose condition precluded transport to the operating room……’

‘……successfully placed on CPB at the bedside within 15mins of cardiac arrest using femoral artery and femoral vein cannulation’

No RCT comparing ECPR with conventional CPR (CCPR)

Limited to observational studies, case series

Propensity- matched modelling to compare ECPR with CCPR

Recent systematic review and meta-analysis

Evidence quality

ECPR for IHCA

Fagnoul D, Combes A, De Backer D. Extracorporeal cardiopulmonary resuscitation. Curr Opin Crit Care. 2014 Jun;20(3):259-65.

3 year prospective observational study (Taiwan 2004-2006)

IHCA >10mins, deemed likely cardiac origin All rhythms included

Primary outcome: survival to hospital D/C Secondary outcomes: 30-day, 1-year survival, rate of ROSC

Propensity matching to compare ECPR vs CCPR

Chen et al……Results

Retrospective 2003-2009, single centre (Korea)

Primary outcome: survival to D/C with CPC 1-2

85 patients ECPR vs 321 patients CCPR

Propensity matched 60 pairs

Shin et al……Results

ECPR for OOHCA

Fagnoul D, Combes A, De Backer D. Extracorporeal cardiopulmonary resuscitation. Curr Opin Crit Care. 2014 Jun;20(3):259-65.

Retrospective, multicentre cohort study (Japan 2004- 2011)

Refractory cardiac arrest (>20mins) due to ACS ECPR combined with PCI

86 patients total 42 OOHCA patients, (29 PCI)

30 day survival with favourable neuro outcome 14% (21% PCI group)

Retrospective review (Berlin 2010-2011)

ECPR for refractory OOHCA

Aim: to identify predictors of mortality in OOHCA ECPR

Mechanical chest compression not used

ECPR in cath lab, followed by Angiography

28 patients

30 day survival rate of 39% (72% survivors had CPC<2)

Only predictor of survival was door to ECMO implantation time

Leick et al……Results

• 35 OOHCA patients• 28% Survival to hospital D/C

1583 studies screened

10 studies (with propensity- based analysis available)

7 patients: 1 survived, 3 brain dead

Cannulation time: 22 mins (+/- 6)

Time to ECMO flow: 57 mins (+/- 21)

26 patients

14/26 (54%) survival to D/C with good neuro outcome

OOHCA survival 3/9 (33%) vs IHCA survival 9/15 (60%)

Retrospective review of outcomes for ECPR cases to date.

Patients identified from ECMO databases in SVH and RPA.

Data gathered from medical charts, databases, and local IT systems:

- Patient demographics- Cardiac arrest details (initial rhythm, downtime

etc…)- ECMO details (setting, cannulation, complications,

duration..)- Echo and Cath lab findings- Intervention details (PCI, CABG, VAD, HTx)- Outcomes and follow-up data

ECPR: the Sydney experience

September 2009- January 2016

42 patients

37 included for analysis

Median age 53yrs (17- 70)

73% male

SVH: n= 23 (62%) RPA: n= 14 (38%)

Results

Overall (%)Predictor of Mortality(p- value)

Initial rhythm VT 19 (51%) 0.25

VF 1 (3%)PEA 14 (38%)Asystole 3 (8%)

Aetiology ACS 11 (30%) 0.79PE 5 (14%)Arrhythmia 3 (8%)Other * 18 (49%)

Location IHCA 25 (68%) 0.87

OOHCA 12 (32%)

Time to ECMO flow (minutes) 52 (+/- 28) 0.42

Arrest data

Number of patientsCoronary vasospasm 1Overdose/ toxins 2Myocarditis 1Chemo- related cardiomyopathy 1Congenital heart disease 1Hyperacute rejection (post-CTx) 1LVAD failure 1Hypothermia 1Sepsis 1Tamponade 1TAVI deployment 2Unclear 3

Aetiology

Angio PCI CABG0

5

10

15

20

25

INTERVENTIONS

54%

24%

3%

Duration in days

ECMO run 4.1 (+/- 3.9)

ICU stay 12.3 (+/- 11)

Hospital stay 20.1 (+/- 19)

ECMO data

Number of patients (%) Predictor of mortality (p- value)

Bleeding event 17 (46%) 0.48

Major bleeding (BARC 3-5)

14 (38%) 0.44

DVT 3 (8%) 0.23

PE 1 (3%) 0.3

Backflow clot 2 (5%) 0.52

Limb ischaemia 7 (19%) 0.63

Haemolysis 1 (3%) 0.46

CVA (embolic) 1 (3%) 0.46

ECMO complications

No. of patients (%)

OOHCA survival 4 (33%)

IHCA survival 9 (36%)

Survival to ICU Discharge 15 (40%)

Survival to Hospital Discharge 13 (35%)

Outcomes

All survivors (13/37) discharged CPC 1/2

Outcomes

Odds ratio (95% CI)

Overall p-value

Pre- ECMO lactate 1.35 (1.06- 1.73) 0.016

Collapse to ECMO flow <60 mins 0.33 (0.06- 1.88) 0.17

Predictors of mortality

ECPR for refractory cardiac arrest:

ECPR outcomes favourable vs conventional CPR

Data gathered from centres with experience and expertise

Development of ‘well- oiled’ systems and protocols crucial to achieve good outcome – Logistics are crucial

If you’re going to do, make sure you do it well

Summary