Given at Case Reports in the Sun, Tampa, FL 2011

1. The Use of a Modernized ExtracorporealLife Support System: A Case Series Dr. Anthony Shackelford DHA, CCP, CCT Assistant Professor Cardiovascular Perfusion Program Medical University of South Carolina Charleston, South Carolina

2. Foreword 2

3. Systematic Review Randomized Control Trials Cohort Studies Case-Control Studies Case Series, Case Reports Just because we do not have a p-value doesn’t mean we’re not “important”!

4. Florida Perfusion Society Board and Members Great Job !! Let’s Give an Applause!! 4

5. Disclaimer 5 I have no contractual or financial affiliations with any of the manufactures of any of the devices mentioned in presentation

6. Case Review 6

7. Patient A: Clinical Presentation 45 year old female Caucasian Pharmacist Presented to outside facility ER with fever 104º F 2 Week history of Flu-like symptoms Cough, Congestion, ache and pain Wide ECG Complex Thought to be V-Tach STEMI protocol initiated Taken to Cardiac Cath Lab Later Diagnosed as Viral Myocarditis 7

8. Patient A: Cath Lab Sequence of Events IABP inserted Catherization performed Coronaries Normal EF = <5% “Almost Cardiac Standstill” Decided to place Impella PEA occurred 10—15 minutes CPR Transferred to MUSC 8

9. Patient A: Arrival in CTICU Impella at 2.2 L/min Mean Arterial Pressure = 35mmHg Neosynephrine, Dopamine, Dobutamine Sinus Tachycardia Oxygenation 100% FiO2 ABG = 7.08/51/196 No corneal, gag or Doll’s eyes reflex Intact brainstem*** 9

10. Patient A: ECLS Placement Patient Heparinized & Drip Started Femoral Cannulation 21 Fr. Arterial / 28 Single Stage Venous ECMO initiated 4.5 L/min Impella flow reduced to 1.0 L/min ** 10

11. Patient A: Hospital Course ECLS Day 2 Patient displayed + neuro signs! ECLS Day 5 Developed left sided weakness Right cerebral embolic stroke / hemorrhage EF was 40% Decided to come off ECLS so that heparin could be discontinued Increased inotropic support 11

12. Patient A: Outcome Displayed some memory deficits continued to resolve over hospital course EF = 40%-50% at day 12 of hospital stay. Day 14 - discharged to home. 12

13. Patient B: Clinical Presentation 62 y/o Female Caucasian Radiology Technologist at outside facility At work in Orthopedic office complaining chest pain Hx reflux for several days EMS called and transfers patient to ER 13

14. Patient B: Sequence of Events Upon Arrival to ER Cardiac Arrest – V-Fib Defibrillated multiple times Transferred to Cath Lab Cardiac Catherization performed Anterior MI EF = 10% - 15% 100% LAD Patient Arrested during DES placement 14

15. Patient B: Sequence of Events CPR performed Perfusion Notified ECLS Primed and Initiated Biomedicus and Primox Pt. was transferred to our facility and switched to our ECLS system. 15

16. Patient B: Events / Outcome CVVH performed during ECLS run DevelopedR/L Arm Weakness MRI - stable subdural hematoma ECLS Day 6 ECLS discontinued IABP inserted Removed at day 3 Pt. discharged to home on hospital day 31 EF 64% No dialysis Improving motor function 16

17. Patient C: Clinical Presentation 20 y/o Black female commissary worker s/p 3 month uncomplicated pregnancy Presents to ER at outside facility Severe Hypotension and Hypoxia Nausa, SOB, substernal chest pain Runs of polymorphic V-Tach Cath Lab No coronary disease EF – 10% IABP placed ->Transferred to MUSC 17

18. Patient C: Arrival in CTICU Perfusion Alerted Patient Heparinized & Drip Started Femoral Cannulation 15 Fr. DLP Fem. Arterial 23 Fr. DLP Fem. Venous ECLS initiated 3.8 L/min Hypoxia and Hypotension resolved! 18

19. Patient C: Outcome ECLS Day 5 Pressors completely off EF was 30% Decided to come off ECLS Restarted pressors Day 14 of hospital stay discharged home EF 60% 19

20. Keys to Success Aggressive Diagnostics Collaboration Medicine/Cardiology/ER/Surgery Early & Aggressive Interventions Right Team /Right Equipment 20

21. Review of our Circuit 21

22. Well First Meet the Old One 22

23. Our Idea is Nothing New 23

24. Schematic Representation of Our Circuit Venous Cell for ILBGM In-line Blood Gas Monitor Blood Flow From Patient Manifold Quadrox Arterial Cell for ILBGM Tandem Heart CentriMag P1 P2 Blood Flow Returning to Patient Gas Line Gas Blender Heater / Cooler

25. A word about ourstaffing model 25

26. Centrifugal Pump Flow Management

27. Oxygenator Blood Gas Management 27

28. Anti-Coagulation Management with ECLS *ACT?? / PTT Anti-Xa Factors (PLT, FIB) AT - III Anti-Xa levels 0.5-0.7 IU/ml

29. ‘Times are a Changing’ 29

30. Perfusion Near-By 30

32. The Future??? 32

33. 2005 33

34. The Future is NOW 34

35. Are there any opportunities left given the advancement of technology? 35

36. If we improve they will come! The hemodynamic stability that CPB provides is still attractive to surgeons Consider OPCAB v PADCAB scenario Bottom Line: Improve Our Technology all tools Continue to market our Skills & Expertise! 36

37. Answering the Call Consider we have come full circle in 50 years! The next level is here Are perfusionistsand manufacturers going to answer the call? 37

38. Conclusion / Recommendations This case series describes our successful use of a modernized ECLS system and model. Given many of the traditional challenges associated with ECLS have been eliminated or greatly reduced it is recommended that any adult cardiac center should consider having a modernized ECLS system readily available as part of their arsenal for treatment of patients with emergent cardiac and/or pulmonary deficiencies. 38

39. Questions 39 shackela@musc.edu

40. Good to Be Back! 40

41. Thank You 41