Joern Tongers

Cardiac awake extracorporeal life support-bridge to decision?

Severe acute heart failure requires immediate intensive care unit (ICU) treatment, but prognosis and outcome of further treatment regimens largely depends on the preprocedural status of the patient. Especially, multiorgan failure including mechanical ventilation are unfavorable predictors of clinical outcome. Here, we report a strategy of immediate initiation of extracorporeal life support (ECLS) in awake and spontaneously breathing patients with acute heart failure to achieve early multiorgan recovery and gain sufficient time for further treatment planning. Twenty-three patients with severe cardiac failure refractory to standard medical management underwent ECLS treatment, after first clinical signs of cardiac failure appeared to avoid mechanical ventilation. Hemodynamic parameters and renal and liver functions were monitored. Outcome at 1 and 6 months was determined. Patients 46.1 ± 15.5 years of age were placed on ECLS due to various underlying diagnosis: ischemic heart disease (n = 6), dilatative cardiomyopathy (n = 4), myocarditis (n = 2), graft failure following heart transplantation (n = 6), or other diseases (n = 5). ECLS lasted 11.9 ± 12.9 days. Hemodynamic stabilization was achieved immediately after ECLS initiation. Vasopressors were reduced subsequently and the cardiac situation improved indicated by central venous saturation, which increased from 38.5 ± 11.3% before to 74.26 ± 8.4% (P < 0.0001) 24 h after ECLS initiation. Similarly, serum lactate levels decreased from 4.7 ± 4.6 to 1.7 ± 1.51 mmol/L (P = 0.003). Cumulative 30-day survival was 87.5%, and 6-month survival was 70.8%. In acute cardiac failure, early ECLS treatment is a safe, feasible treatment in awake patients allowing a gain of time for final decision. Moreover, this strategy avoids complications associated with sedation and mechanical ventilation and leads to recovery of secondary organ function, enabling destination therapy.

TCT-22 Dual Mechanical Support Combining Impella Microaxial Pump and Veno-arterial ECMO Rescues High-risk Patients in Refractory Cardiogenic Shock

nos: 21 24 TCT-21 Door-to-ECMO before Door-to-Balloon? Early Implementation of ECMO might improve the Survival of Patients with STEMI Complicated by Refractory Cardiogenic Shock Chi-Cheng Huang, Pen-Chih Liao, Shin-Rong Ke, Jung-Cheng Hsu Far Eastern Memorial Hospital, Taipei City, Taiwan; Far Eastern Memorial Hospital, New Taipei City, Taiwan, Taiwan; Far Eastern Memorial Hospital; Taipei, Taiwan BACKGROUND Refractory cardiogenic shock (RCS) represents the extremely-ill patients with STEMI, whose mortality rate was >60%. Despite the efforts to decrease door-to-balloon (D2B) time in the past decade, recent studies reported little progress on mortality of these patients. Meanwhile, early mechanical support such as ECMO has shown some favorable results when combined with primary PCI. D2B time delayed by ECMO has been a concern, but few studies addressed it. METHODS From January 2005 to December 2014, 1969 patients presented with STEMI received emergent cardiac catheterization; revascularization was conducted by PCI or CABG as appropriate. ECMO was performed for 46 patients with RCS, defined as SBP <90mmHg under inotropes, refractory ventricular arrhythmia, or cardiac arrest. Demographic, hemodynamic, and angiographic data were collected retrospectively. Comparison was made between patients whose ECMO were set up before (N1⁄412) and after (N1⁄434) the cardiac catheterization. RESULTS Between two groups, there was no difference in age (before vs. after, 56.9 vs.57.5), male gender (91.7% vs. 85.3%), calendar year, GRACE score (median, 178 vs. 184), BP at ED (84/47 vs. 97/59) or before ECMO (50/34 vs. 58/32), number of diseased vessels (mean, 2.5 vs. 2.4), complete revascularization during PCI (41.7% vs. 23.5%, p1⁄40.276), and TIMI 3 flow after PCI (81.8% vs. 56.0%, p1⁄40.453). Patients with ECMO performed before PCI had a lower door-to-ECMO time (median 63 vs. 609 mins, p1⁄40.019) and a nonsignificant longer D2B time (145 vs.115 mins, p1⁄40.469); however, they had a significantly better 6-month survival (58.3% vs. 14.7%, p1⁄40.006). After adjusting for gender, GRACE and D2B time, ECMO implemented before the cardiac catheterization is independently associated with 6-month survival (OR 1⁄4 7.03 [95% CI 1.10-44.00], p1⁄4 0.039). All except 1 survivor had good neurological output. CONCLUSION Our data demonstrated a strong association between early ECMO implementation and survival in STEMI patients with RCS. Unlike previous studies, our finding highlights a new hypothesis – should we pause for ECMO before rushing for the D2B time? RCT is strongly needed to examine these results. CATEGORIES CORONARY: Acute Myocardial Infarction TCT-22 Dual Mechanical Support Combining Impella Microaxial Pump and Veno-arterial ECMO Rescues High-risk Patients in Refractory Cardiogenic Shock Joern Tongers, Jan-Thorben Sieweke, L Christian Napp, Florian Zauner, Dominik Berliner, Christian Kühn, Axel Haverich, Johann Bauersachs, Andreas Schäfer Hannover Medical School, Hannover, Germany; Brigham and Womens Hospital; Hippokratio hospital; Hannover Medical School; The Jikei University School of Medicine; Medical Clinic IV Department of Cardiology, Municipal Hospital Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Germany; Royal Bournemouth Hospital, Bournemouth, United Kingdom; Mayo Clinic College of Medicine; Geisinger Health System BACKGROUND Despite advances in management of cardiogenic shock (CS), its mortality remains unacceptably high particularly if refractory. The evolving field of mechanical support including extracorporeal membrane oxygenation (ECMO) and Impella microaxial pump has revolutionized treatment strategies. However, questions regarding mechanical support such as timing and management remain elusive. Experience in the combination of ECMO and Impella intending on biventricular unloading are lacking. METHODS In our single-center registry, 55 consecutive patients with refractory CS received dual mechanical support using Impella and venoarterial (VA) ECMO (female-male 18/82%, age 53 2 yrs). Cardiogenic shock resulted from cardiomyopathy (40%), STEMI (17%), NSTEMI (7%), and arrhythmia (15%). During the ICU-course patients were critically ill: e.g. 93% mechanical ventilation, 53% dialysis, 38% resuscitation. Impella and VA ECMO were inserted and removed percutaneously via femoral access (duration of dual support: 107 72 hrs). RESULTS The length of ICU-/in-hospital stay was 12 2 and 27 5 days. On mechanical support, hemodynamics stabilized, while use of catecholamines could be saved (dobutamine: BL 5.6 4.2, 24-hrs 2.9 3.1, 72-hrs 2.2 2.7 mg/kg/min, p<0.0001 vs. BL; norepinephrine BL 0.5 0.6, 24-hrs 0.2 0.3, 72-hrs 0.2 0.3 mg/kg/min, p<0.0001 vs. BL). Reflecting the microcirculation, lactate levels normalized over time (BL 8.5 6.4, 24-hrs 2.4 1., 72-hrs 2.1 2.4 mmol/L, all p<0.05 vs. BL). Despite the negative selection of CS patients with a historically devastating prognosis, in-hospital survival in our fragile population was 42%. While 19 patients were bridged to recovery, 13 patients were bridged to VAD-implantation. After its successful weaning mechanical support had not to be reinstalled in any patient. The safety profile of dual support was reasonable (e.g. 11% DIC, 7% leg ischemia, 7% stroke, 6% compartment). Vascular access site problems occurred in only 3 patients. B10 J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 8 , N O . 1 8 , S U P P L B , 2 0 1 6 CONCLUSION In conclusion, the concept of dual mechanical support using Impella microaxial pump combined with VA ECMO for biventricular unlading in refractory CS is feasible and efficient in stabilizing and rescuing patients at highest risk. CATEGORIES CORONARY: Hemodynamic Support and Cardiogenic Shock TCT-23 Contemporary Trends in Utilization of Mechanical Circulatory Support in Patients Hospitalized After Out-of-Hospital Cardiac Arrest Nileshkumar Patel, Nish Patel, Gabriel Hernandez, Shilpkumar Arora, Apurva Badheka, Abhishek Deshmukh, Eduardo DeMarchena, Mauricio Cohen, Carlos Alfonso, Deepak Bhatt, Navin Kapur University of Miami, MIAMI, Florida, United States; University of Miami Miller School of Medicine, Miami, Florida, United States; Novosibirsk State Research Institute of Circulation Pathology; Mount Sinai st luke’s roosevelt, New York, New York, United States; Yale university, New haven, Connecticut, United States; UAMS erwqeqweqw, little rock, Arkansas, United States; University of Miami, Miami, Florida, United States; University of Miami Hospital, Miami, Florida, United States; University of Miami Miller School of Medicine, Miami, Florida, United States; Brigham and Women’s Hospital, Boston, Massachusetts, United States; Tufts Medical Center, Boston, Massachusetts, United States BACKGROUND There are few data on the contemporary trends in utilization of mechanical circulatory support (MCS) in patients who hospitalized after out-of-hospital cardiac arrest (OHCA). METHODS We conducted an observational analysis of patients hospitalized after OHCA between January 2007 and December 2013 from the Nationwide Inpatient Sample database. The use of MCS was determined using ICD-9-CM, procedure codes. These included intra-aortic balloon pump (IABP) (ICD-9: 37.61), percutaneous ventricular assist device (PVAD) (ICD-9: 37.68), and extracorporeal membrane oxygenation (ECMO) (ICD-9: 39.65). We also compared trends of survival to hospital discharge in patients with and without MCS use. RESULTS Of 968,083 OHCA, MCS was used in 49,565 (5.1%) of the patients. IABP was the most commonly used MCS after OHCA with frequency of 46,371 (4.8%), followed by ECMO 2,904 (0.3%), and PVAD 2,323 (0.2%). Overall trend of MCS increased by 33% from 4% in 2007 to 5.4% in 2013 (Ptrend<0.001). Trend of IABP used increased by 18.6% from 2007 to 2013 (4% to 4.7%, Ptrend<0.001), whereas PVAD utilization increased by 410% (<0.1% to 0.5%, Ptrend<0.001), and ECMO by 430% (0.1% to 0.5%, Ptrend<0.001). Overall survival to discharge was significantly higher in patients who were selected to have MCS (56.5% vs. 41.9%, p-value<0.001). Survival to discharge increased significantly in both groups (MCS group: 50.5% to 57.6%, Ptrend<0.001; No MCS group: 36% to 46.9%, Ptrend<0.001) over the study period (see figure). CONCLUSION PVAD and ECMO utilization have increased significantly in comparison to IABP in patients with OHCA. OHCA patients who were selected to have MCS use had better survival to discharge. Randomized studies are required to validate our observations. CATEGORIES CORONARY: Hemodynamic Support and Cardiogenic Shock TCT-24 Global cVAD Registry: A global initiative in percutaneous circulatory support From the cVAD Steering Committee on behalf of all cVAD Investigators Brijeshwar Maini, Jeffrey Moses, Simon Dixon, Mark Anderson, William Lombardi, Jacob Eifer Møller, Jose Henriques, Andreas Schafer, Theodore Schreiber, E. Magnus Ohman, William O’Neill Tenet Florida, Delray Beach, Florida, United States; NewYorkPresbyterian Hospital/Columbia University Medical Center, New York, New York, United States; Beaumont Hospital, Royal Oak, Michigan, United States; Albert Einstein Health Network; University of Washington Medical Center, Seattle, Washington, United States; Odense University Hopital, Odense, Denmark; Academic Medical Center University of Amsterdam, Amsterdam, Netherlands; Sakakibara Heart Institure; DMC, Warren, Michigan, United States; Duke University Medical Center, Durham, North Carolina, United States; Henry Ford Hospital, Detroit, Michigan, United States BACKGROUND Percutaneous circulatory support has an exponential growth within the last decade. In the era of evidence based medicine and appropriate use, having a systematic, standardized conduit for clinical data in “real world” medical setting becomes paramount. Objective: To build a comprehensive depository data collection system that monitors current usage and provides quality metric