IABP to prevent pulmonary edema under VA-ECMO · IABP to prevent pulmonary edema under VA-ECMO ... ↘ LV work et ↘ LV volume ... Days of IABP 4.7 ± 4.4 1–17

IABP to prevent

pulmonary edema

under VA-ECMO

Alain Combes

Service de Réanimation

iCAN, Institute of Cardiometabolism and Nutrition

Hôpital Pitié-Salpêtrière, AP-HP, Paris

Université Pierre et Marie Curie, Paris 6 www.reamedpitie.com

Conflict of interest

Principal Investigator: HEROICS trial HVHF after complicated heart surgery

NCT01077349

Sponsored by GAMBRO

Principal Investigator: EOLIA trial VV ECMO in ARDS

NCT01470703

Sponsored MAQUET, Getinge Group

Received honoraria from MAQUET, Getinge Group

Gambro

Pulmonary edema

under VA ECMO

Pulmonary edema

Due to an increase in LV afterload created by the backward ECMO flow

More frequent With peripheral ECMO

If no residual LV ejection

Increase in LV afterload Aortic/Mitral regurgitation, LV dilation

↗ LV end-diastolic pressure, ↗ PCWP

Pulmonary edema

Laminar flow Alteration of microcirculation?

Pulmonary edema under VA-ECMO

Diastolic inflation

↗ coronary blood flow

↗ myocardial O2 supply

↘ myocardial ischemia

Systolic deflation

↘ afterload et ↗ cardiac output

↘ myocardial O2 consumption

↘ LV work et ↘ LV volume

Pulsatile blood flow

Improvement of microcirculation?

Hemodynamic impact of the IABP

Retrospective study

December 2007 to December 2012

457 peripheral VA-ECMO

90 patients with laminar flow

LVEF <15%

ITV < 8 cm

Δ SBP-DBP <15mmHg

2007-2012 457 PVA ECMO

Post-cardiotomy 117 Refractory MOF<48h 96 Chronic pulmonary disease 26 Massive mitral regurgitation 21 Refractory septic shock 14 Femoro-axillary cannulation 10 ARDS 8 Isolate RV dysfunction 8 Prior impella implantation 5

Pulse pressure≥ 15 mmHg 48 or TVI ≥8 cm

IABP for APO 5 APO after IABP explantation 5 ECMO centralisation for other reasons than APO 4

90 patients

No-IABP 56

IABP 34

Patients’s characteristics

Parameter Median (25th-75th)

No-IABP n=56

IABP n=34

p

Age, y 46,5 (32-54) 51,5 (43-59,5) * 0,02 Male, % 57 % 73 % 0,12 BMI 24,6 (20,6-27,8) 26,6 (24,8-30,7) * 0,02 Charlson score 2 (1-3) 2 (1-3) 0,14 Year 2009 (2008-2010) 2011 (2010-2012) ***p<0,0001 Saps-II score 65 (56-72,5) 75 (54-81) 0,11 SOFA score 11 (6,5-13) 11 (8-14,5) 0,39 Etiology, %

Cardiac arrest AMI Myocarditis DCM

28,5% 35,7% 32,1% 32,1%

41,1% 64,7% 11,7% 23,5%

0,22

** 0,007 *0,03 0,38

Inotrope score, g/kg/min 76,5 (41-127,5) 49 (30-77) *0,03 LVEF, % 10 (7-10) 10 (6-11) 0,73 TVI, cm 4 (2-5) 4 (2-5) 0,38 Mechanical ventilation, % 87,5 % 94,1 % 0,42 PaO2/FiO2 ratio 270 (155-326) 296 (170-376) 0,69 PEEP, cmH2O 4 (2-5) 4 (4-6) 0,14 pH 7,25 (7,18-7,35) 7,25 (7,12-7,32) 0,40 Lactatemia, mmoles/L 8,0 (5,7-10,9) 7,3 (5,0-11,5) 0,98 Q ECMO, L/min 3,97 (3,33-4,45) 4,22 (3,73-4,61) 0,09

Radiologic component of the LIS

No IABP

IABP

Radiologic score

Time from ECMO implantation

D0 D1 D2 D3 D7 D150

1

2

3

4

*** *** ***

***

Percent survival free from

Pulmonary edema

0 5 10 150

10

20

30

40

50

60

70

80

90

100

110

IABP

No-IABP

Time (days)

P<0,0001 by Logrank test

Impact of IABP use

2006 2007 2008 2009 2010 2011 2012 20130

25

50

75

IABP

switch for central ECMO

Major pulmonary edema

Need for central ECMO

- +0

25

50

75

100

IABP

44.6% vs 5.9%

***, p=0.0001

Independent predictors of pulmonary

edema occurrence

Variables OR IC 95% P

No IABP 18.87 4.3-90.97 <0.0001

pH <7.25 at ECMO

initiation 4.47 1.19-16.80 0.027

Inotropic Score >66

at ECMO initiation 5.0 1.43-18.87 0.013

Outcomes

Parameter Median (25th-75th)

No-IABP n=56

IABP n=34

p

IABP duration, d - 5,5 (3,5-7,5)

ECMO duration, d 5 (2,5-7,5) 6 (4-10) 0,06

Follow-up, % Death under peripheral ECMO Death under central ECMO Death under temporary assistance Myocardial recovery Cardiac transplant Bridge to long term assistance

12,5 14,2 32,1 35,7 17,9 14,3

26,5

0 26,5 35,3 5,9 32,3

0,09

- 0,57 0,97 0,10 0,04*

Weaning from MV under ECMO, % 30,4 38,2 0,44

Time on MV under ECMO, % 100 (66,3-100) 100 (40,4-100) 0,52

ICU mortality, % 35,7 29,4 0,54

ICU duration, d 14 (6-30) 10 (6-21) 0,24

Temporary circulatory assistance duration, d

9 (5,5-13) 6 (4-10) 0,13

Mechanical ventilation duration, d 6 (3-15) 5 (3-12,5) 0,29

RRT duration, d 5,5 (1-42) 2 (0-6) 0,69

Prospective study

Study objectives

Evaluate the impact of the combination of

Peripheral veno-arterial ECMO

Counterpulsation with IABP

On general hemodynamics and

microcirculation

In patients with refractory cardiogenic

shock

Methods

Prospective monocenter crossover study

12 months-study period

12 patients

Admitted for refractory cardiogenic shock

requiring emergent peripheral veno-arterial ECMO

Low or non-ejecting heart : laminar blood flow

Evaluation

Evaluation under IABP support, after 30 min

interruption and 30 min after restarting the IABP

Evaluation of macrocirculation

Clinical parameters

Arterial blood pressure

Echocardiographic parameters

Aortic VTI, LVEF, LVEDD, LVESD

E/A and E/Ea ratios, mitral annulus S wave

CO, CI

Pulmonary artery catheter:

PAPs, PAPd, PAPm, PAOP

Blood gases

Sidestream Dark Field

imaging SDF

Sublingual videomicroscopy

sequences

Semi-quantitative and

dynamic evaluation of

microcirculation

Evaluation of microcirculation

InSpectra® StO2 - NIRS

Early indicator of tissular hypoperfusion?

• Models : arteriopathy, septic shock

Parameters :

• Baseline StO2

• Vascular occlusion test VOT : T1, T2

• Hyperemia (StO2 overshoot)

Thenar eminence microcirculation

Equanox ® Nonin

Early indicator of brain hypoperfusion

• Models : cardiac surgery

Parameters :

• Left and right rSO2

Brain microcirculation

Variable Value Range

Age, yr 57 ± 14 28–75

Men, n (%) 9 (75%)

SAPS2 79 ± 16 65–106

Before inclusion

Days of ECMO 6.3 ± 5.9 1–21

Days of IABP 4.7 ± 4.4 1–17

Diagnosis, n (%)

Acute myocardial infarction 8 (67%)

Acute valvular dysfunction 2 (17%)

Dilated cardiomyopathy 1 (8%)

Fulminant myocarditis 1 (8%)

During study protocol

ECMO flow, L/min 4.3 ± 0.9 3–5.5

Catecholamines

Dobutamine (n = 4), µg/kg/min 7.5 ± 3.0 5–10

Norepinephrine (n = 1), mg/h 0,6

Epinephrine (n = 5), mg/h 3.0 ± 4.0 0.35–10

Patients on mechanical ventilation, n (%) 12 (100%)

Patients’ characteristics

Parameter IABP on IABP off IABP

restart P

Heart rate 99 ± 21 101 ± 17 103 ± 20 0.07

SBP (mmHg) 103 ± 20 102 ± 20 100 ± 22 0.75

DBP (mmHg) 74 ± 17 88 ± 16 72 ± 16 0.02

MBP (mmHg) 87 ± 14 92 ± 16 84 ± 16 0.06

Pulse pressure (mmHg) 29 ± 22 15 ± 13 29 ± 24 0.02

DBP increase (mmHg) 134 ± 40 – 125 ± 26 –

Hemodynamic data

Pulmonary artery catheter

Parameter IABP on IABP off IABP

restart P

SBP, mmHg 24 ± 9 29 ± 11 23 ± 10 0.01

DBP, mmHg 16 ± 7 19 ± 10 16 ± 9 0.04

MBP, mmHg 19 ± 8 24 ± 10 19 ± 9 0.02

PAOP, mmHg 15 ± 8 19 ± 10 15 ± 8 0.01

Central venous oxygen saturation, % 73 ± 11 73 ± 15 75 ± 12 0.43

IABP to prevent pulmonary

edema under peripheral ECMO P

ulm

onary

A

rtery

Occlu

sio

n P

ressure

Parameter IABP on IABP off IABP

restart P

LVEDD (mm) 52 ± 14 55 ± 13 47 ± 13* 0.003$

LVESD (mm) 50 ± 14 51 ± 13 42 ± 13* 0.05$

Velocity–time integral (mm) 25 ± 13 25 ± 14 26 ± 15 0.85

Cardiac output (l/min) 0.79 ± 0.46 0.77 ± 0.78 0.81 ± 0.74 0.85

Diastolic velocity

Transmitral early peak (E) (cm/s) 49 ± 19 61 ± 25 51 ± 26 0.07

Transmitral late (A) (cm/s) 32 ± 13 31 ± 9 31 ± 12 0.10

E/A 1.26 ± 0.38 1.95 ± 0.66 1.33 ± 0.36 0.003

Lateral mitral early annular (Ea) (cm/s) 6.4 ± 2.8 6.4 ± 2.5 5.8 ± 1.9 0.44

E/Ea 8.6 ± 4.0 9.8 ± 2.6 9.2 ± 4.3 0.31

S (cm/s) 4.9 ± 2.5 5.0 ± 2.9 4.9 ± 2.3 0.90

Echocardiographic data

Near-infrared spectroscopy IABP on IABP off IABP

restart P

Thenar

Baseline StO2, % 82 ± 6 79 ± 8 82 ± 6 0.41

Tissue desaturation during VOT, (%/s) –0.13 ± 0.06 –0.13 ± 0.06 –0.14 ± 0.08 0.56

Range –0.04;–0.23 –0.02;–0.24 –0.03;–0.28

Tissue resaturation after VOT (%/s) 1.26 ± 0.76 1.28 ± 0.70 1.28 ± 0.58 0.21

Range 0.56;–3.20 0.67;2.55 0.57;2.95

Cerebral hemisphere rSO2

Right, % 69.1 ± 5.3 69.4 ± 5.1 69.9 ± 5.3 0.76

Left, % 67.4 ± 5.5 68.6 ± 4.0 68.9 ± 5.3 0.24

NIRS data

200

300

400

100

50

0

FCD

(cm

/cm

²)M

FIP

PV

(%

)

IABP on

He

tero

gen

eit

y in

dex

IABP off IABP on again

200

300

400

100

50

0

FCD

(cm

/cm

²)M

FIP

PV

(%

)

IABP on

Het

ero

gen

eity

ind

ex

IABP off IABP on again

200

300

400

100

50

0

FCD

(cm

/cm

²)M

FIP

PV

(%

)

IABP on

He

tero

gen

eit

y in

de

x

IABP off IABP on again

200

300

400

100

50

0

FCD

(cm

/cm

²)M

FIP

PV

(%

)

IABP on

He

tero

gen

eit

y in

dex

IABP off IABP on again

SDF sublingual imaging

If Pulmonary edema

occurs…

Impella 5.0

Conclusion

For cardiogenic shock patients with little/no residual LV ejection while on peripheral VA-ECMO

Restoring pulsatility and decreasing LV afterload with IABP Associated with smaller LV dimensions and

lower pulmonary artery pressures

But no impact on microcirculation parameters

IABP might prevent severe hydrostatic pulmonary edema in this context

May 21-24 2014