Outcomes with ECMO for In Hospital Cardiac Arrest

Subhasis Chatterjee, MD, FACS, FACC, FCCP.

ECMO Program Director

CHI Baylor St. Lukes Medical Center/ Texas Heart Institute

Asst. Professor of Surgery, Baylor College of Medicine

American Association for Thoracic Surgery . Mechanical Circulatory Support SymposiumMarch 8, 2018. Houston, TX

Disclosures• Nothing

In Hospital Cardiac Arrest (IHCA)

•1. Outcomes of IHCA with Conventional CPR•2. Results of Outcomes of ECMO in IHCA•3. Prognostic Factors predicting success/failure

•4. Conduct of ECMO•5. Complications

• 13 to 22% Survival to Hospital Discharge (STHD)

• 33% to 28% for significant neurologic disability

Girotra. NEJM 2012;367:1912-20.

Uchenna R. Ofoma et al. JACC 2018;71:402-411

2018 American College of Cardiology Foundation

IHCA: Public Perception of CPR

• Public perception: 75% watch medical dramas

• 57% believed an 80yo man with IHCA would survive with complete recovery. 1

• 72% believe that chance of full recovery after IHCA CPR is 75%. 2

2 Shif. Resuscitation 2015;90:73-78.1 Ouelette. Amer. Jrnl Emerg Med. 2018 IN PRESS

Goldhaber ZD. Lancet 2012;380:1473-81.

-- 49% ROSC; 15% STHD-- + ROSC= 12 min (6-21) CPR- Hosp. in Longest quartile CPR 25” vs. 16” had higher ROSC (51 vs. 45%) & STHD (16 vs. 14%)

What do the Guidelines Tell Us about Extracorporeal CPR (E-CPR)?

•Not Much

Brooks SC. CIRCULATION 2015;132(18 Supp2):S436-43.

Monsieurs KG. Resuscitation 2015;95:1-80

ELSO ECPR

• E-CPR is defined as ECMO initiation during CPR without ROSC or in patients with transient ROSC

• Defines refractory CPR after 15”• Total Body Hypothermia should be

included– ice to head during CPR and for 48-72 hrs after cannulation

Outcomes

1976N=3541% survival

ECPR outcomes in IHCAStudy, Country Design N Age (yrs)

Male (%)Time to ECLS (mts)

Neurologically Favorable Survival

Chen et al (2008)Taiwan

Prospective 59 18-75 <3030-4545-60>60

42%30%30%18%(33% Overall)

Lin et al (2010)Taiwan

Prospective 59 5985%

40 24%

Shin et al. (2011)Taiwan

Retrospective

85 6062%

42 28%

Chou et al. (2014)Taiwan

Retrospective

43 6193%

60 35%

Zhao et al. (2014)China

Retrospective

24 5979%

36 33%

Blumenstein et al (2016) Germany

Retrospective

52 7254%

33 21%

Chen. Lancet 2008;372:554-561. Lin. Resuscitation 2010;81:796-803. Shin. Crit Care Med. 2011;39:1-7. Chou. Emerg Med. Jrnl 2014;31:441-447. Zhao. Eur J Med Res. 2015;20:83. Blumenstein. Eur Hrt Jrnl. J Acute Cardiovasc Care 2016;5:13-22.

Challenges in Interpreting the E-CPR Literature•1. What is E-CPR ? Is it cannulation during CPR vs. cannulation immediately after ROSC with ongoing CS ?

•2. Selection bias in E-CPR over C-CPR – felt to be “more salvageable”

Outcomes: Meta-analyses

30-day survival for CA= 36% (23-50%) vs. CS= 53% (44-61%)

- ECPR better survival (RR=2.37) and Neuro (2.79) than CCPR- ECPR no significant difference in IHCA but was in OHCA

40% ECMO Survival30% STHD

27% Survival

IHCA Outcomes

• 3 year Prospective Observational Study

• Age 18-75• Witnessed IHCA and CPR>10”• ECMO (n=59) vs. Conv CPR

(n=113) Propensity matched

Chen YS. Lancet 2008;372:554-561.

ECPR

CCPR

19% @ 1y29% @ 30d

12% @ 30d 10% @ 1y

Chen YS. Lancet 2008;372:554-561.

Prognostic Factors

Duration of CPR to Survival Discharge

Chen YS. Lancet 2008;372:554-561.

Duration & Survival

<30” = 63% > 30” = 29%

<45” = 50% > 45” = 22%

<60” = 47% > 60” = 9%

Chen YS. Crit Care Med 2008;36:2529-35

Age, CPR duration, Rhythm, ROSC

Lee SW. Ann Intensive Care 2017;7:87.

Lactate < 4.6

88%

44%

HR 3.55 (2.29-5.49, p<0.001)

Jung. Clin Res Cardiol 2016;105:196-205

Time to Coronary Intervention Matters

Chou TH. Emerg Med J 2014;31:441-47.

20%

40%

60%

80%

100%

Who Should Not Have ECMO with IHCA

Patel JK. Jrnl Int Care Med 2016;31:359-68

Age<75VF/VT>>> OtherCPR start < 5-15”Cardiac/PE causeNo ROSC after 10-20”

Terminal illnessMajor comorbiditiesCNS Disease/ICHBleeding/AC ContraindSepsis ArrestAD/AI/PVD

Conduct of E-CPR

Lee. Lancet 2008;372:512-4.

Swol J. Perfusion 2016;31:182-88.

10-20”

Cannulation• Who Should Cannulate ? Where ?

• Surgeons• Cardiologists• Intensivists• ER Physicians

• Tradeoff– Risk of Complications vs. Rapid Cannulation• Watch Out for Inadvertent Malposition i.e. VV or AA

E-CPR Algorithm

N=26 (15=IHCA, 11=OHCA)

92% had ECMO

Median 56”54% STHD

Mechanical CPRHypothermiaECMOEarly Reperfusion

Stub. Resuscitation 2015;86:88-94.

Complications

20 studies; 1866 patients

Cheng. Ann Thorac Surg 2014;97:610-6.

17% LE Ischemia10% Fasciotomy5% Amputation

6% Stroke13% Neurologic

45-55% AKI/RRT40% Major Bleed/Takeback30% Infection

Cheng. Ann Thorac Surg 2014;97:610-6.

ECMO Program Volume

0

20

40

60

80

100

120

140

2014 2015 2016 2017

E-CPR Survival Rate

0

5

10

15

20

25

2016 2017

<7% Survival

Perc

ent S

urvi

val

Bloom HL. Am Heart J. 2007;153(5):831-6.

ECMO Program Changes at Baylor St. Lukes/Texas Heart Institute

•Joined ELSO•Monthly Case Review Meetings•Routine Neurocritical Care Consultation•Routine Hematopathology Consultation (PTT, TEG, antiXa)

E-CPR Survival Rate

0

5

10

15

20

25

2016 2017

Perc

ent S

urvi

val

Conclusions

•20-30% STHD for IHCA•Witnessed arrest, rapid CPR, VT/VF, < 60” to ECMO

•Higher rate of complications

Questions

Subhasis.Chatterjee@bcm.edu