Yanno on ECPR
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We do an EDECMO ECPR course each year called REANIMATE. REANIMATE5 blew away all previous iterations. One of the main reasons was our guest of honor, Demetris Yannopoulos from the University of Minnesota. Demetris has organized Minneapolis into arguably the most impressive ECPR city in the world. We were lucky enough to be able to film his Sharp Hospital Grand Rounds. This lecture was mind-blowing and made us so jealous. We think you will love it.
Tickets are on Sale for REANIMATE6
Additional Info/Resources
- EDECMO 36 – Zack interviews Demetris
- EDECMO Crash Episode – Microdissection of Demetris’ ECPR Techniques
- JAHA Publication on ECPR Results
- In-Depth Look at their Protocol [Resuscitation 2018;132:47
Great talk by Dr. Yannopoulis. I’d like to comment on some of the points that was brought up:
1) The point brought up regarding in-house arrest is interesting and worth elaborating on. It is somewhat unusual to have an ECPR program and during the time frame that over 140 OHCA were treated with ECPR no in-house arrests occurred or treated with ECPR. Most places starting an ECPR program begin with offering ECPR to in-house in-emergency room pts first.
2) I am very surprised that in a series of over 140 ECPRs no cases required LV unloading. As brought up the participating audience, bronchial flow can comprise 1-3% of cardiac output. This translates to 100-150 mls/min of blood flow into LA and subsequently into LV. Despite Dr. Y’s sugestion VA-ECMO does NOT fully unload the LV. In a severely compromised LV that is not able to eject against the afterload posed by VA ECMO (i.e. flat arterial trace or aortic valve not opening on echo) it’s imperative to unload LV using inotropes, perc LVAD (Impella, Tandem) or a vent line. This is important not only for pulmonary edema but to increase the likelihood of LV recovery.
3) In describing how there is no flow through PA on VA-ECMO Dr. Y suggested that in cases in which PE was suspected he performed pulmonary angiogram while turning down ECMO and performing manual CPR. This does not make any anatomical/physiological sense. Having performed multiple cases of ECPR for PE (as recent as three weeks ago), all you have to do is to perform a standard CT angio of chest for PE while on VA-ECMO. There is always blood flow through PA despite VA-ECMO and PE can easily be delineated.
4) Average ECMO support of 1-4 days and hospital stay of 7-14 days in a case series of 140 ECPR is remarkable and quite unusual. I was quite surprised by how few pts required VAD support in this series. In our experience as many as 30% of pts post ECPR will require LVAD/RVAD/BiVAD support either as a bridge to recovery/transplant or DT.
Regards,
Hossein
1. it is not that there were no in-house arrests getting ECPR, it is that Dr. Yannopoulis doens’t handle those.
2. Yes, we were ALL surprised. And we still can’t reconcile with our own experiences.
3. We have had quite lousy CT angios on VA-ecmo as well. I wonder if the ? is one of image timing rather than the contrast never getting there.
4. That is the crux, isn’t it. and it surely is not do to short downtimes with 65 min being the average. so the ? is what is different. immediate cath may be part of it. it sounds like they give a lot more time for the patient to generate a recovery as well.
Thanks Scott. Just got back from Euro ELSO. While aside from Alain Combes NEJM paper there were no big revelations however had great discussions surrounding some of the above points with experts from large ECMO centers. It was comforting to see our experience was the same as the experts. With regards to the above
2. Some experts argued that a heart on VA-ECMO post ECPR should always be vented to maximize the myocardial recovery. Makes physiological sense but no data to support this. Again, we can’t relate/understand the Minneapolis experience.
4. Between 20-40% conversion to VADs is seen at other major centers such as Alfred and Columbia. I don’t think the explanation is the immediate cath. I actually think is the fact that pt who did not have a perfusing rhythm were turned off. This ties in to point number 2. In cardiac surgery often after removal of cross clamp pt will go into VF. LV gets distended grossly. We know for a fact it’s very difficult to cardiovert the pt out of VF if it’s a sick distended LV. Fortunately we frequently have a LV vent in for cardiac cases and thus we can still shock them out of VF after cross clamp removal.
By not supporting the pts who did not have perfusing rhythm after 1 hour of ECMO you are eliminating very bad hearts that have low survival or will end up needing VAD. If you think about it there is no rationale to turn off an PEA/asystolic heart as long as the pt is a candidate for transplant. I suspect if you vent those hearts after ECMO placement they can be cardioverted to perfusing rhythm. However you will not have 40% survival or 0% VAD conversion.
agree with all of that. what do you think of a patient who stays in asystole or agonal rhythm after placement on pump. we had a case like this at Janus General even though initial rhythm in the field was VF. It seemed to all involved, including me, that this was representative of a dismal prognosis, but I have no data to back this up.