Doctors, Don’t give up yet!

1. Doctors, Don’t give up yet! • Dr. Anfernee YIM, RS, AICU/PWH • Dr. Philip Lam, AC, AICU/PWH

2. Case 1 • 48/F • DM, HT, pAF on warfarin • CRHD • TEE: EF 50-55%, moderate dilated LA, rheumatic MS with calcified mitral apparatus, moderate MS with moderate to severe MR, MVA around 1.3cm2 • Cardiac catheterization: 40% LAD distal, normal LCx/RCA • Increasing exertional retrosternal chest pain for 1/12, decrease exercise tolerance to 10 minutes level ground • Bilateral ankle edema on regular lasix • Clinically admitted for MVR + AF ablation

3. Developed SVT with profound hypotension, responsive to synchronized cardioversion x 2 • Developed acute severe PHT resulting in PEA shortly after the SVT episode, CPR started, down time 2 minutes • Developed second episode of severe acute PHT shortly after sternotomy, severe profound hypotension, resuscitated with 100% O2, Calcium and Adrenaline, internal cardiac massage and then went to CPB immediately

4. MVR: 25mm Sorin bileaflet mechanical valve • However RV and LV not contracting well • Attempted to come off CPB with IABP but failed and patient was re-cannulated • Three more attempts but resulted in hypotension and ST changes • Central ECMO • Ascending aortic cannula and 2-stage venous cannula • Connect to centrifugal pump and brought out via the xiphi sterni, chest closed • Bypass time 244 + 73 + 64 minutes • Ischaemic time 56 minutes

5. CPB with ECMO circuit ready

6. CPB converted to Central V-A ECMO

7. CPB converted to Central V-A ECMO

8. CPB converted to Central V-A ECMO

9. Post-op to ICU • DDD pacing 80/min • Noradrenaline 7microgram/min • Transamine / Heparin / Amiodarone infusion • Sedated & paralyzed

11. Post-op Vitals • Temp 36.5C • BP 113/57 P 80/min • SpO2 100% FiO2 0.4 on ECMO • U/O 40ml/hr • Drain output 200ml/hr • Cold peripheries, all distal pulses present • ABG: pH 7.414 pCO2 3.22 pO2 47 BE -8.1 • H’cue 9.6 H’stix 10.6 ACT 119

12. 2 days later...... • Back to OT again • Improved RV and LV contractility • Marked decrease in RV and LV distension • Normal functioning MV prosthesis • ECMO weaned with IABP and dopamine

14. Recurrent AF, not responsive to amiodarone and cardioversion • Complications • AKI, urea 19.9, Cr 117 • Elevated ALT, 501 normal bilirubin ? ischaemic hepatitis • Thrombocytopenia, 50 • Leucocytosis, 17.6 • IABP weaned 2 days afterwards • Vasopressors/sedation weaned the following day • Requiring GTN infusion and oral metoprolol • Extubated to NIV 6 days after the primary event • Discharged from ICU 12 days after the primary event, no neurological deficit

15. Case 2 • 31/F • Prolapse of AV with perforation and severe MR, LV decompensated in March, 2009 • Prolapsed AV, RCC leaflet, severe AR • Dilated LV, EF 39% • Mild functional MR with tethered leaflets • AVR in May, 2009, RCC significant ruptured and dilated, no ostium • Post-op complicated with moderate peri-prosthetic leak around RCC, small pericardial effusion • Plan for Redo AVR if LV function get worse or worsening symptoms

16. Clinical admission to cardiac TMH in July, 2010 • Echo: AVR in-situ with perivalvular leak, moderate to severe MR, Mild TR, RVSP 26mmHg, pericardial effusion, satisfactory LV systolic function, mildly impaired RV relaxation • Worsening SOB on exertion 1 week prior admission • Developed intermittent heart block, temporary transvenous pacing inserted • Transferred PWH for further management

17. AV repair 26.7.2010 • Difficult procedure requiring repeated exploration • Aortic prosthesis site dishesience • Repair attempt but still perivalvular leak at the end of the procedure • CPB time 4 hours requiring adrenaline during coming off CPB • Extubated in the next early morning

18. Sweating, dizziness, sinus tachycardia 104/minute • Repeated Echo: • New AR over aorto-mitral junction • Small pericardial effusion • LV mildly dilated • LVEF 55-60% • Symptoms improved with diuretics • Plan for the third Redo AV repair +/- replacement

19. Bentall operation on 3.8.2010 • Aortic valvular and ascending aorta replacement, coronary artery inclusion • Severe dehisence of mechanical valve over NCC of aortic root, single coronary sinus with two ostia over the posterior aspect, no right coronary ostia seen • Upon attempt coming off CPB, TEE showed ? flask like mass over PMVL and moderate to severe MR, protamine withheld and re-heparinisation • LA atriotomy, thrombus removed and AMVL, PMVL and annulus looked normal and no rupture chordae seen

20. Then coming off CPB successful initially • On table assessment showed satisfactory contractility of Rt and Lt heart and protamine commenced, then femoral venous cannula removed • However noted profound hypotension afterwards and need to go back to CPB • Repeated several times with increasing inotropes • IABP inserted but still failed to provide stable haemodynamics • TEE: very good LV contractility • Central VA ECMO set up • Ascending aorta, SVC cannula and left femoral vein cannula

24. Post-op to ICU • DDD pacing, runs of atrial extrasystole requiring amiodarone infusion • Sedated and paralysed • Cold extremities • BP 79/37, MAP 52mmHg on 7mcg/min Noradrenaline • HR 95/min paced • IABP 1:1 augmentation • ECMO blood pump 3L, FGF 3L/min

27. OT again 3 days later • Overall improve RV function and contractility • ECMO weaned with dopamine • Upon decannulation of Lt femoral venous line noted no back flow from LL, Forgarty balloon thrombolectomy done and clot removed with resultant good back flow • Fine adjustment of the IABP as well, 1:1 augmentation then • Weaned off IABP 3 days afterwards and extubated the following day and discharged from ICU the next day

29. Case 3 • 52/M • Transferred back from mainland by SOS • Post out of hospital VF cardiac arrest, down time 40 minutes • VA ECMO for 7-8 hours • Cardiac catheterization with PCI to LAD • Complicated with complete heart block • Good neurological recovery, extubated • Complicated with AKI on CRRT, derangement of LFT, Rt LL painful erythematous swelling with lost of Rt dorsalis pedis, CPK more than 10000 in mainland before transferral • Bedside USG revealed Rt femoral vein clot/thrombus and not compressible • Echo did not reveal any evidence of PE but incidental finding of initimal flap over the desending aorta • CT revealed type A aortic dissection, necrotic Rt deep compartment

30. Refer to QuickTime Video 1

31. Refer to QuickTime Video 2

33. ECMOExtracorporeal Membrane Oxygenation, VA

34. Configurations for ECMO • Central ECMO Peripheral ECMO

37. Post-cardiotomy Syndrome (PCS) • Systolic arterial hypotension (<80 mm Hg) and signs of end-organ failure, anaerobic metabolism, and metabolic acidosis • Cardiac index less than 1.8 L/m2 body surface area and PCWP of at least 20mmHg. • Unable to wean off By-pass

38. Post-cardiotomy Syndrome (PCS) • Number of Open-heart surgery in PWH 08-09 ~ 312 • PCS potentially requiring Mechanical Circulatory Support ~ 0.5 - 1.5 %, ie 2 to 4 cases per year.

39. Advantages of ECMO in cardiogenic shock • Rapid/easy implantation for peripheral ECMO • No sterno/cardiotomy, LA, emergency setting • Provide high flow, up to 7L/min • Bridge to recovery or transplantation • Low cost, 2-40 times cheaper than other devices • Mobile, may facilitate transfer

40. When to initiate mechanical assistance? • Cardiogenic shock refractory to conventional treatment, including IABP • Parameters to evaluate • Causes/time course of the disease • Treatment initiated and response • Clinical status especially neurological state • ? Futile

41. Limitations • Time: 15-21 days for Femoral VA ECMO • Up to 2 months • Remain in supine position • Local complications: • Haemorrhage, embolism, LL ischaemia, infection • Stroke: ischaemic vs haemorrhagic • Highly pre and afterload dependent for the pump • Non pulsatile flow?

42. ICU management of ECMO

43. ECHO is important

44. ECHO • At the time of cannulation • Confirm the position of the cannula • Daily surveillance • Recovery of the cardiac function, facilitate weaning • Look for complications, pericardial effusion, tamponade, intra-cardiac clot

45. Long term QOL

47. Maintenance of ECMO • Need off-loading for the heart to rest • Right ventricle by ECMO • Left ventricle with IABP or LV vent for AR to avoid LV distension • ECMO flow is volume dependent – hence avoid hypovolemia, cannula malposition, PTx and cardiac tamponade • Avoid hypertension as centrifugal pump is afterload dependent • Protective lung ventilation with low plateau pressure and low tidal volume/RR

48. VA Central ECMO • Chest remained open may increase risk of bleeding from sternum and infection

49. Literature review

50. Use of ECMO in cardiac surgery