Presented at the Egyptian ECMO day by Dr Malaika Mendonca

1. ECMO Post Cardiac Surgery
Dr Malaika Mendonca
Division Chief, Pediatric Cardiac Surgical Intensive Care
Director ECMO Program
ELSO South and West Asia Chapter Co-Chairman
Sheikh Khalifa Medical City, Abu Dhabi UAE
9th January 2017

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Objectives:
• Discuss Indications
• Compare Cannulationstrategies
• Describe Monitoring
• Explain possible complications
• Discuss Outcome Data

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Extracorporeal Life Support Organization (ELSO)- Data:

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Post–CardiotomyCardiogenic Shock (PCCS)
• Occurs in 2-6% of patients undergoing revascularization or
Valvular surgery (or combination)
• Inability to wean from cardiopulmonary bypass or extreme
hemodynamic instability in the immediate postoperative phase
• About 1% of these patients are refractory to maximal inotropic
support and intra-aortic balloon pump (IABP)
• PCCS happens to patients with preoperative normal myocardial
function and to those with pre-impaired function

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Associated with in-hospital
mortality of around 50%
What is the role of
advanced mechanical
support?
ECMO post-cardiac surgery?
Is this a reversible cause?
Bridge to recovery?
Bridge to transplant?
Bridge to assist device?
Post–CardiotomyCardiogenic Shock (PCCS)

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Central: open or closed ?
Cannulation strategies:

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Peripheral cannulation: A. axillaris/subclavia

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Peripheral cannulation: A. femoralis
• Distal perfusion cannula to be inserted
• Competitive flow : own contractility and ECMO flow

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Cannulation and considerations:
• Increasing afterload with femoral arterial cannula
• Lung on ventilator rest setting:
Ejected blood from LV has same oxygen content as right
atrium!!! – PaO2 around 35 and Sat around 75%
Coronary perfusion!!!!
• Leg / arm ischemia must be considered / prevented
• Cannula size should be able to provide adequate flow: 60 ml/kg
How do we know, we have adequate flow ?

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Monitoring:
1. Adequate oxygen delivery: Lactate level, Central Venous
Saturation, Urine output

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Monitoring:
2. Anticoagulation/Bleeding
3. Neurostatus
4. Leg ischemia
5. Ventilation/Pulmonary edema

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Myocardial Stunning:
NO own contractility
results in:
Complication:
• :
 Risk of stagnation and thrombus in left ventricle
 Increased LVED and overdistention will impair coronary
perfusion
 Increased LVED and overdistention -> Dilatation and
regurgitation -> Pulmonary edema
What now?

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• ECLS flow about 80% cardiac output to achieve pulsatile flow or
insertion of a drain into the LA
• Adequate ventilation to ensure good coronary perfusion by the
native cardiac output
Left Ventricular Decompression:

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Patient on VA ECMO, both cannulas left femoral
Sat on monitor: 68%
ABG taken from R femoral
art line:
PaO2: 398 mmHg
CO2: 35 mmHg
Sat: 100%
=> What has happened?

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Complication: Harlequin Phenomenon
• Cardiac contractility improves
• Lungs not well or not ventilated
-> return of deoxygenated blood
from lungs to LA
• Ejection of deoxygenated blood
Cave: Coronary and cerebral
perfusion!

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Outlined two very specific problems or complications, which may
occur depending on contractility and recovery of contractility:
1. Myocardial Stunning with need of LV decompression
2. Harlequin Phenomenon with need for ejection of oxygenated
blood from LV

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Complications:

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Outcome:

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Author
Publication
Year -
Reference
Patient nr. Prevalence
In-Hospital
Survival
1-Year
Survival
Fiser 2001 51 0.9% 16% na
Ko 2002 76 2.6% 26.3% 23.6%
Smedira 2002 107 na na na
Hsu 2010 51 2.9% 33% 29%
Wu 2010 110 2.7% 40.3% 24.5%
Rastan 2010 518 1.3% 24.8% 16.5%
Elsharkawy 2010 239 0.58% 36% na
Pokersnik 2012 49 na 32.6% na
Slottosch 2013 77 na 30%a na
Unosawa 2013 47 na 51% 29.8%
Loforte 2014 118 0.96% 46.6% na
Saxena 2015 45b na 24.4% 24.4%
Khorsandi 2016 16c na 31.2% 31.2%
Polimenakosd 2011 14ˆ na 57% na
Zhaoe 2015 24 na 33% na
Prevalence:
0.5% - 2.6% (1.7%)
In-Hospital Surv.:
16% - 57% (34.4%)
1-Year Surv.:
16.5% - 31.2% (25.6%)
Outcome:

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Outcome prediction:

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Outcome prediction:
www.save-score.com

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Outcome prediction:
Younger age, lower weight, acute myocarditis, refractory VF or VT,
higher diastolic pressure and lower peak pressure were found to
be protective

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Outcome prediction:
Score of 0 has a survival
chance of 50%

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• Post-CardiotomyECMO/ELS still represents the Most Common
Indications for VA ECMO
• Outcome is unsatisfactory, but great potential for
Improvement (timing, complication prevention, appropriate
configuration, patient management, prophylactic ECMO)
• Further Research is mandatory (results, predictors, score, …)
• Multi-Disciplinary Tasks & Working Groups are desired
• Extracporeal Life Support Organisation (ELSO) has a critical
Role and Responsability to lead this project (multi-society
partnership)

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