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Mechanical Circulatory Support for Failing Right Ventricle in PAH
1. Mechanical Circulatory Support of the
Failing Right Ventricle
Corey E. Ventetuolo, MD, MS, FAHA
Associate Professor of Medicine, Departments of Medicine, Health Services Policy & Practice
Associate Chief, Division of Pulmonary, Critical Care & Sleep Medicine
Medical Director, Adult ECLS Program
15th Annual NC Research Triangle Pulmonary Hypertension Symposium
November 17, 2023
2. Disclosures
Consultant: Regeneron, Merck, Janssen
Advisory boards: United Therapeutics, Merck, Janssen
PI, Study Co-Chair: NHLBI funded clinical trials
DSMBs: Elafin, H01/SATURN
Intellectual bias: I believe ECLS works
3. Mechanical Circulatory Support for the RV
I will not be talking about MCS for the RV in the context of LV
failure, bridge to LVAD/heart transplant, or axial flow device
Kapur, Circulation 2017
4. ECLS Alphabet Soup
ECPR: Extracorporeal CardioPulmonary
Rescusciation
VA ECMO: Veno-Arterial ExtraCorporeal
Membrane Oxygenation
VV ECMO: Veno-Venous ExtraCorporeal
Membrane Oxygenation
ECCO2R: ExtraCorporeal CO2 Removal
Triple and quadruple configurations
Modifying traditional cardiopulmonary bypass
circuit, outside of the OR
Ventetuolo & Muratore, AJRCCM 2014
5. Two Consults for PH and Extracorporeal Life Support
MICU Consult
ARDS, low tidal volume ventilation
Hemodynamically stable
TTE: severe RV dilatation, severe
dysfunction, septal flattening,
RVSP 80 mm Hg
OB/GYN Consult
30 yo connective tissue disease, 27 weeks
pregnant
Syncope
RA 15, PA 82/45/57, PAOP 2, CO TD 2.15,
PVR 26, PA sat 31%
Rudder & Ventetuolo, NEJM 2021
6. Some Caveats
Treating PH has become more complicated
Treating PH + ECLS is even more complicated, and experiential
These cases require multidisciplinary collaboration
7. ECLS in the Management of PAH:
Not a Treatment but a Bridge
To Recovery
To Destination (Transplant)
To Decision
8. Determine etiology and
transplant candidacy
Not a transplant
candidate
Transplant
candidate
ECMO as bridge to recovery ECMO as bridge to
transplant
• Progressive disease-related
decompensation despite
maximal medical therapy
• Contraindication for ECMO
• Acute decompensation due to
treatable illness
• Suboptimal medical
management
• No contraindication to ECMO
Supportive care Optimize PAH therapy
PT/OT, wean PAH
therapy
PAH with RV
failure
Adapted from Rosenzweig, ASAIO 2014
Destination first
10. PH/RV Failure and Extracorporeal Support
Cardiac support
CDH
PPHN
PAH
PE
Post-cardiotomy
Pulmonary support
Mild “secondary” PH
ARDS
VV-ECMO
ECCO2R
VA-ECMO
Alternative configurations
12. Use of ECLS to unload the RV and minimize deleterious
effects on PVR
Hypoxemia
Hypercapnia
Acidemia
Mechanical ventilation
Disselkamp, Annals ATS 2018
13. VV-ECMO: May have subtle effects on RV function
Miranda, AJRCCM 2015
13 patients with acute respiratory failure
No significant change in CI (TD)
No change in pressor requirements
10 patients with ARDS
Schmidt, Int Care Med 2013
14. Evidence that ECCO2R May be a Reasonable Approach in
Select Patients with PH/RV Failure
5 patients with AECOPD
Philipp, Muller, Int Care Med 2015
15. The REST Trial, ECCO2R
McNamee, JAMA 2021
Serious Events
31% ECCO2R vs 9% control
4.5% ICH ECCO2R group
16. Approach to RV Failure in PAH
Awake VA-ECMO
Preload: diuresis
RV ischemia: SBP>90, vasopressors
Afterload: gas exchange, PAH therapy
Contractility: inotrope
Reverse triggers: optimize MV, treat
infection
Mullin & Ventetuolo, Clin Chest Med 2021
Medical optimization
Preload: ultrafiltration
RV ischemia: stop vasopressors
Afterload: gas exchange, ± PAH
therapy
Contractility: stop inotrope
Reverse triggers: awake
17. Six month survival after BLTx 80% awake ECMO vs 50% historical
MV group (p = 0.02)
Required shorter postoperative MV and hospital LOS
12% (MV) and 27% (awake) had PAH/CTEPH as underlying
diagnosis (p=0.13)
24% (MV) and 42% (awake) had mPAP > 30 mm Hg (p=0.12)
Am J Respir Crit Care Med 2012
18. There remains clinical equipoise for the use of ECMO in
cardiogenic shock. PH/RV failure is an even larger gap.
ECLS-SHOCK ECMO-CS
Thiele, NEJM 2023
Ostadal, Circulation 2023
19. Appropriate candidate selection for VA-ECMO:
SAVE-Score
Parameters Score
Diagnosis Myocarditis +3; VT/VF +2;
post H/Ltx +3; congenital -3
Age 18-38 +7; ≥ 63 0
Weight (kg) 65-89 +2
Pre-ECMO organ failures Liver, CNS, Renal -3; CKD -6
Pre-ECMO duration intubation, hr 11-29 hrs -2; ≥ 30 hrs -4
PIP ≤ 20 mm Hg +3
Pre-ECMO cardiac arrest -2
Pre-ECMO DBP ≥ 40 mm Hg +3
Pre-ECMO pulse pressure ≤ 20mm
Hg
-2
Pre-ECMO HCO3 ≤ 15 mmol/L -3
Constant -6
Total SAVE Score -35 – +17 Schmidt, Eur Heart J 2015
There are no absolute
contraindications for ECMO
In PH, it is often bridge to decision
20. Determine etiology and
transplant candidacy
Not a transplant
candidate
Transplant
candidate
ECMO as bridge to recovery ECMO as bridge to
transplant
• Progressive disease-related
decompensation despite
maximal medical therapy
• Contraindication for ECMO
• Acute decompensation due to
treatable illness
• Suboptimal medical
management
• No contraindication to ECMO
Supportive care Optimize PAH therapy
PT/OT, wean PAH
therapy
PAH with RV
failure
Adapted from Rosenzweig, ASAIO 2014
21. Bridging to Recovery in PAH:
Possible Clinical Scenarios
PAH treatment naïve
Newly diagnosed
No parenteral therapy
Pregnant
Require surgery, procedure
Volume overload
Arrhythmia
Sepsis
Acute decompensation due to treatable illness
Suboptimal medical management
No contraindication to ECMO
Optimize PAH therapy
22. Specific Considerations for PAH Therapies During ECLS
Almost all are hepatically cleared
Lipophilic
Highly protein bound (91-99%)
Very limited data suggests highly variable levels, efficacious dosages
during ECLS
PO sildenafil in 11 neonates (Ahsman, Arch Dis Child Fetal Neonatal Ed 2010)
IV Treprostinil in 5 neonates (De Bie, Pharmacotherapy 2020)
Flow through native pulmonary circulation will impact systemic effects
Implant and explant, weaning
Circuit changes
Flow adjustments
24. Dynamic Adjustments to PAH Therapy are Required
during ECMO
Torbic, J Cardiovasc Pharmacol Ther 2022
25. Determine etiology and
transplant candidacy
Not a transplant
candidate
Transplant
candidate
ECMO as bridge to recovery ECMO as bridge to
transplant
• Progressive disease-related
decompensation despite
maximal medical therapy
• Contraindication for ECMO
• Acute decompensation due to
treatable illness
• Suboptimal medical
management
• No contraindication to ECMO
Supportive care Optimize PAH therapy
PT/OT, wean PAH
therapy
PAH with RV
failure
Adapted from Rosenzweig, ASAIO 2014
26. Alternate configurations to support PAH patients
bridging to transplant and recovery
PA-LA, 2-3.5 L/min
VV-ECMO + ASD with oxygenated shunt
Upper body VA configuration
Schmid, Ann Thorac Surg 2008
Strueber, Am J Transplant 2009
Rosenzweig, ASAIO 2014
27. Veno-pulmonary (OxyRVAD) and veno-veno-pulmonary
configurations to support the RV
Case series demonstrating possible RV
protection in severe COVID-ARDS
Case series using OxyRVAD as a bright to
LTx in PH
Concern for pulmonary overflow > high
PVR > microhemorrhage
Joyce, JTCVS 2021
Cain, J Surg Res 2021
Cain, JTCVS 2022
Mustafa, Ann Surg 2021
Lee, JHLT 2020
Usman, JCTS 2023
28. Increase in the use of prophylactic ECMO during lung
transplant, LV reconditioning in PAH
21 (42%) had post-operative LV dysfunction
26 (52%) required ECMO
Increasing use of prophylactic ECMO over study period
48/50 (96%) survived
Otto, Crit Care 2022; Tudorache,
Transplantation 2015; Pereszlenyi, Eur J
Cardio-thorac Surg, 2002; Ko, Artificial Organs
2001; Ko, Transpl Proc 1999
29. Awake ECMO after lung transplantation in PAH for LV
reconditioning
Tudorache, Transplantation 2015
Pereszlenyi, Eur J Cardio-thorac Surg, 2002
Ko, Artificial Organs 2001
Ko, Transpl Proc 1999
30. Role of ECMO in Management of PAH
IIa: Should be
considered
C: Consensus,
small/retrospective
studies
31. Experienced centers may have better outcomes
Freeman, CCM 2014
Karamlou, J Thorac Cardiovasc Surg 2013
Barbaro, Am J Respir Crtic Care Med 2015
Hayes, Am J Respir Crtic Care Med 2016
32. Two Consults for PH and Extracorporeal Life Support
MICU Consult
ARDS, low tidal volume ventilation
Hemodynamically stable
TTE: severe RV dilatation, severe
dysfunction, septal flattening,
RVSP 80 mm Hg
OB/GYN Consult
30 yo connective tissue disease, 27 weeks
pregnant
Syncope
RA 15, PA 82/45/57, PAOP 2, CO TD 2.15,
PVR 26, PA sat 31%
Rudder & Ventetuolo, NEJM 2021
VV-ECMO
or
Veno-Pulmonary
VA-ECMO
35. Take Home Points: ECLS for the Failing RV
Determine etiology and plan for bridge
Involve PH team, multidisciplinary collaboration
Beware systemic vasodilation and “recirculation”
Dynamic adjustments in PAH therapy (IV/inhaled) when BTR
Awake VA-ECMO is “standard”
Novel configurations, much more to learn, durable support may be
possible
37. Acknowledgments
Patients and families who participate in research
Funding:
AHA, 11FTF7400032
NIH, P20 GM103652
NHLBI, R01 HL141268
Parker B. Francis (Adeel Abbasi)
Brown University
James Klinger
Elizabeth Harrington
Christopher Mullin
Navneet Singh
Katherine Cox-
Flaherty
Mary Whittenhall
Britt Ferland
Kayla Thatcher
Rachel Sanders
Grayson Baird
Carsten Eickhoff
Mandy Pereira
Amy Princiotto
Adeel Abbasi
Editor's Notes
13 subjects with acute resp failure
PA catheter 6 hours after cannulation
Two patients awaiting transplant; mPAP 26 and 43 mm Hg before ECMO
No significant change in CI
No change in pressors
CI measured by TD
Acute, potentially reversible cause of moderate to severe hypoxemic respiratory failure
MV > 5 PEEP, within 48 hrs of PaO2/FiO2 < 150
Among 412 patients who were randomized (mean age, 59 years; 143 [35%] women),
405 (98%) completed the trial. The trial was stopped early because of futility and feasibility
following recommendations from the data monitoring and ethics committee. The 90-day
mortality rate was 41.5%in the lower tidal volume ventilation with extracorporeal carbon
dioxide removal group vs 39.5%in the standard care group (risk ratio, 1.05 [95%CI,
0.83-1.33]; difference, 2.0%[95%CI, −7.6%to 11.5%]; P = .68). There were significantly
fewer mean ventilator-free days in the extracorporeal carbon dioxide removal group
compared with the standard care group (7.1 [95%CI, 5.9-8.3] vs 9.2 [95%CI, 7.9-10.4] days;
mean difference, −2.1 [95%CI, −3.8 to −0.3]; P = .02). Serious adverse events were reported
for 62 patients (31%) in the extracorporeal carbon dioxide removal group and 18 (9%) in the
standard care group, including intracranial hemorrhage in 9 patients (4.5%) vs 0 (0%) and
bleeding at other sites in 6 (3.0%) vs 1 (0.5%) in the extracorporeal carbon dioxide removal
group vs the control group. Overall, 21 patients experienced 22 serious adverse events related
to the study device.
CONCLUSIONS AND RELEVANCE
The secondary outcomes are presented in Table 2. Therewere
significantly fewer ventilator-free days at day 28 in the intervention
group (7.1 [95% CI, 5.9-8.3] vs 9.2 [95% CI, 7.9-10.4]
days;meandifference,−2.1days [95%CI,−3.8to−0.3];P = .02).
There was no significant between-group difference in duration
of ventilation,needforECMOat day 7, mortality at28days,
or duration of ICU or hospital stay.
In this multicenter trial, patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early ECLS plus usual medical treatment (ECLS group) or usual medical treatment alone (control group). The primary outcome was death from any cause at 30 days. Safety outcomes included bleeding, stroke, and peripheral vascular complications warranting interventional or surgical therapy.
RESULTS
A total of 420 patients underwent randomization, and 417 patients were included in final analyses. At 30 days, death from any cause had occurred in 100 of 209 patients (47.8%) in the ECLS group and in 102 of 208 patients (49.0%) in the control group (relative risk, 0.98; 95% confidence interval [CI], 0.80 to 1.19; P=0.81). The median duration of mechanical ventilation was 7 days (interquartile range, 4 to 12) in the ECLS group and 5 days (interquartile range, 3 to 9) in the control group (median difference, 1 day; 95% CI, 0 to 2). The safety outcome consisting of moderate or severe bleeding occurred in 23.4% of the patients in the ECLS group and in 9.6% of those in the control group (relative risk, 2.44; 95% CI, 1.50 to 3.95); peripheral vascular complications warranting intervention occurred in 11.0% and 3.8%, respectively (relative risk, 2.86; 95% CI, 1.31 to 6.25).
CONCLUSIONS
In patients with acute myocardial infarction complicated by cardiogenic shock with planned early revascularization, the risk of death from any cause at the 30-day follow-up was not lower among the patients who received ECLS therapy than among those who received medical therapy alone. (Funded by the Else Kröner Fresenius Foundation and others; ECLS-SHOCK ClinicalTrials.gov numb
In the ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock), immediate implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) did not improve outcomes compared with no immediate VA-ECMO in patients with severe or rapidly deteriorating cardiogenic shock.
●
A large proportion (39%) of patients in the no early VA-ECMO group subsequently received VA-ECMO or other mechanical circulatory support because of further hemodynamic deterioration.
What Are the Clinical Implications?
●
Even in patients with severe or rapidly deteriorating cardiogenic shock, early hemodynamic stabilization using inotropes and vasopressors with implementation of mechanical circulatory support only in case of further hemodynamic deterioration provided outcomes that were not different from immediate insertion of VA-ECMO
Extracorporeal membrane oxygenation (ECMO) may provide mechanical pulmonary and circulatory support for patients with cardiogenic shock refractory to conventional medical therapy. Prediction of survival in these patients may assist in management of these patients and comparison of results from different centers.
AIMS:
To identify pre-ECMO factors which predict survival from refractory cardiogenic shock requiring ECMO and create the survival after veno-arterial-ECMO (SAVE)-score.
METHODS AND RESULTS:
Patients with refractory cardiogenic shock treated with veno-arterial ECMO between January 2003 and December 2013 were extracted from the international Extracorporeal Life Support Organization registry. Multivariable logistic regression was performed using bootstrapping methodology with internal and external validation to identify factors independently associated with in-hospital survival. Of 3846 patients with cardiogenic shock treated with ECMO, 1601 (42%) patients were alive at hospital discharge. Chronic renal failure, longer duration of ventilation prior to ECMO initiation, pre-ECMO organ failures, pre-ECMO cardiac arrest, congenital heart disease, lower pulse pressure, and lower serum bicarbonate (HCO3) were risk factors associated with mortality. Younger age, lower weight, acute myocarditis, heart transplant, refractory ventricular tachycardia or fibrillation, higher diastolic blood pressure, and lower peak inspiratory pressure were protective. The SAVE-score (area under the receiver operating characteristics [ROC] curve [AUROC] 0.68 [95%CI 0.64-0.71]) was created. External validation of the SAVE-score in an Australian population of 161 patients showed excellent discrimination with AUROC = 0.90 (95%CI 0.85-0.95).
CONCLUSIONS:
The SAVE-score may be a tool to predict survival for patients receiving ECMO for refractory cardiogenic shock (www.save-score.com).
Wisconsin
End-stage PH Ltx Alfred Hospital
Retrospective
LV dysfunction decrement in EF by 15%
After transplant, normalized LV preload
23 BLTx patients – severe PAH, sarcoid, IPAH, CTEPH
PVR 1400 dynes, RVEF 34%, CI 2, mPAP 66 prior
100% 90 day survival
Severe PH > LV diastolic dysfunction from small, stiff LVs > early PGD