Slides for a talk by Vincent Pellegrino (ECMO Director at The Alfred ICU) on ECPR. For videocast and audio only versions of this talk go to the RAGE podcast (http://ragepodcast.com/ecpr-vincent-pellegrino/) or The Alfred ICU's INTENSIVE blog (http://intensiveblog.com/ecpr-vin-pellegrino/).

1. The Alfred Intensive Care Unit, Melbourne, Australia
The use of VA ECMO following Cardiac Arrest
E-CPR
Vincent Pellegrino
Aidan Burrell
Steven Bernard
Richard Lin
Deirdre Murphy
Lloyd Roberts
Jayne Sheldrake
Carol Hodgson
D. Jamie Cooper
Vinodh Nanjayya
Bishoy Zachary
Daniel Brodie

2. The Alfred Intensive Care Unit, Melbourne, Australia
Cardiac
Arrest
VA ECMO Survival
Condition Treatment Outcome
Assessing the impact of E-CPR

3. The Alfred Intensive Care Unit, Melbourne, Australia
Assessing the impact of E-CPR
Out Hospital
CA
VA ECMO Survival
Condition Treatment Outcome
In Hospital
CA
+ROSC +CS
+ROSC +CS
- ROSC
- ROSC
Neuro
Cost
QOL
Organ
Donation
Unsupportable

4. The Alfred Intensive Care Unit, Melbourne, Australia
Approach
1. Define the population considered for E-CPR
(Who?)
2. Examine the different approaches to E-CPR
(how?)
3. Outcomes from E-CPR (what seems to work?)
4. Going forward

5. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Alfred Hospital - Melbourne
ECMO commenced within 30
minutes of a cardiac arrest
which has been associated
with c-CPR for greater than
10 minutes or has rendered
the patient unconscious
Based on the CA
definition for therapeutic
hypothermia
i.e. the CA has contributed to the
patient neurological outcome

6. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Taipei, Taiwan JACC 2003
“Briefly, patients were recruited into the
ECPR group only if they: 1) were in cardiac
arrest that necessitated external or open-
chest cardiac massage and a large amount
of epinephrine (5 mg) during CPR; 2) could
not be returned to spontaneous circulation
within 10 to 20 min; and 3) subsequently
received ECMO in the hospital”
no ROSC ROSC+

7. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Japan, SAVE-J 2014

8. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
ELSO: Ann Thor Surg 2009
“The registry defines E-CPR as the following:
“extracorporeal life support (ECLS) used
as part of initial resuscitation from cardiac
arrest. Patients who are hemodynamically
unstable and placed on ECLS without cardiac
arrest are not considered E-CPR” [1].
no ROSC ROSC+

9. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Korea
“The ECPR was defined as use of venoarterial
ECMO intended to treat cardiac arrest”
“received veno-arterial ECMO upon the
recurrence of CA within 20 min after the
return of spontaneous circulation
(ROSC) or due to no signs of ROSC
after >10 min of CPR following AMI-
induced CA (Figure 1). All patients
underwent ECMO during ongoing
continuous chest compressions”

10. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Korea
“In previous studies, the definition of ECPR included both
successful veno-arterial ECMO implantation and pump-on
during cardiac massage [10,11]. However, various
unexpected situations occurred in ongoing ECPR scenes.
Actually, when a return of spontaneous circulation (ROSC)
occurs during ECMO cannulation, the practitioner does not
remove the already inserted cannula and does not stop the
process of ECMO pump-on. We included such cases in our
ECPR definition as intention-to-treat. Accordingly, ECPR
was defined as an intention-to-treat with hemodynamic
ECMO support during cardiac massage regardless of
interim ROSC [11]”
no ROSC ROSC+

11. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
The Problem
The majority of patients that may benefit
from emergency ECMO following cardiac
arrest have some return of circulation
Also, it is common for patients receiving
ECMO for cardiac failure to have had a
preceding CA
Universal definitions of ROSC are lacking
Cardiac arrest occurs in many different
settings (in hospital and out of hospital)
no ROSC ROSC+
IHCA OHCA+

12. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Does it matter much…?

13. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Does it matter much…?

14. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
Does it matter much…?

15. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
How to proceed … ?
Out of Hospital

16. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
How to proceed … ?
In Hospital

17. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the Condition:
• Cardiac Arrest Definitions
• Patient Diagnostic Groups
• Cardiac Arrest Rates
How to proceed … ?

18. The Alfred Intensive Care Unit, Melbourne, Australia
21 minutes

19. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Defining the condition
Cardiac arrest of greater than
20 min (conventional CPR)
Sub-classifications
• Pathological Classification
• +/- ROSC
• + out-of-hospital
• (initial rhythm)
Diagnostic groups

20. The Alfred Intensive Care Unit, Melbourne, Australia
Patient Population (Who?)
Exclusion Criteria
These will vary greatly from
centre to centre

21. The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO
Cannulation
-Percutaneous or Open
Cannulae
Temperature
O2 tension

22. The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO
Cannulation
-Percutaneous or Open
Cannulae
Temperature
O2 tension

23. The Alfred Intensive Care Unit, Melbourne, Australia
Cannulation
Percutaneous with
ultra-sound guidance
and distal perfusion
cannula

24. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia
Assessment of Vascular Access
TTE - subcostal
TOE - transgastric
Inferior Vena Cava

25. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia
Assessment of Vascular Access
Abdominal Aorta
Aorta (TTE subcostal)
PW Doppler aorta

26. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia
J-wire in IVC
Venous Cannulation for ECMO

27. The Alfred Intensive Care Unit, Melbourne, Australia
Downstream compression

28. The Alfred Intensive Care Unit, Melbourne, AustraliaThe Alfred Intensive Care Unit, Melbourne, Australia
VA ECMO Backflow Cannulation
CFA
Profunda Artery
SFA

29. The Alfred Intensive Care Unit, Melbourne, Australia
Coming ….very soon!!

30. The Alfred Intensive Care Unit, Melbourne, Australia
MTMM bidirectional cannula

31. The Alfred Intensive Care Unit, Melbourne, Australia
MTMM bidirectional cannula
Transition zone role in downstream compression

32. The Alfred Intensive Care Unit, Melbourne, Australia

33. The Alfred Intensive Care Unit, Melbourne, Australia
Out Hospital
CA
VA ECMO Survival
Condition Treatment Outcome
In Hospital
CA
+ROSC +CS
+ROSC +CS
- ROSC
- ROSC
Neuro
Cost
QOL
Organ
Donation
Unsupportable

34. The Alfred Intensive Care Unit, Melbourne, Australia
VA ECMO Maintenance:
Cardiac Management:
Left Ventricular Failure
Causes
Severe left ventricular failure
with any AR or MR
• Fatal pulmonary
hemorrhage
Severe AR/MR with LV
ejection
First sign = Access
Insufficiency

35. The Alfred Intensive Care Unit, Melbourne, Australia
VA ECMO Maintenance:
Cardiac Management:
Left Ventricular Failure
Causes
Severe left ventricular failure
with any AR or MR
• Fatal pulmonary
hemorrhage
Severe AR/MR with LV
ejection
First sign = Access
Insufficiency

36. The Alfred Intensive Care Unit, Melbourne, Australia
Alternative cannulation

37. The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO
Cannulation
-Percutaneous or Open
Cannulae
Temperature
O2 tension
The change to 36 degrees as a
targeted temperature has not
been successful at our centre
due to the low use of internal
cooling devices

38. The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO
Cannulation
-Percutaneous or Open
Cannulae
Temperature
O2 tension

39. The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO
Cannulation
-Percutaneous or Open
Cannulae
Temperature
Blood-flow, Gas-flow
O2 tension

40. The Alfred Intensive Care Unit, Melbourne, Australia
Approaches to E-CPR (How?)
Time to ECMO
Cannulation
-Percutaneous or Open
Cannulae
Temperature
O2 tension

41. The Alfred Intensive Care Unit, Melbourne, Australia
Training and team

42. The Alfred Intensive Care Unit, Melbourne, Australia
Team work

43. The Alfred Intensive Care Unit, Melbourne, Australia
Management of the AMI CA
ST-AMI
Cath lab
PCI
CABG

44. The Alfred Intensive Care Unit, Melbourne, Australia
Management of the AMI CA
ST-AMI +CA
E-CPR
PCI
CABG
Cath lab

45. The Alfred Intensive Care Unit, Melbourne, Australia
Management of the AMI CA
ST-AMI +CA + ROSC
or +Shock
E-CPR
PCI
CABG
Cath lab
Other resus

46. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(What seems to work?)
SAVE-J study
Propensity Matching
ELSO
Risk Prediction
-Biomarkers
Organ Donation
Strongest trial design
for E-CPR

47. The Alfred Intensive Care Unit, Melbourne, Australia
Out of Hospital Cardiac Arrest Survival
and ECMO

48. The Alfred Intensive Care Unit, Melbourne, Australia

49. The Alfred Intensive Care Unit, Melbourne, Australia

50. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(What seems to work?)
SAVE-J study
Propensity Matching
ELSO
Risk Prediction
-Biomarkers
Organ Donation

51. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(What seems to work?)
SAVE-J study
Propensity Matching
ELSO
Risk Prediction
-Biomarkers
Organ Donation

52. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR

53. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR

54. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(2+) 5/30 (16%) 12/32 (37.5%)

55. The Alfred Intensive Care Unit, Melbourne, Australia
WWW.SAVE-SCORE.COM
WWW.RESPSCORE.COM
Risk adjustment for adult patients undergoing ECMO for cardiac support 2003 to 2013
Risk adjustment for adult patients undergoing ECMO for respiratory support 2000 to
2012
ELSO Adult Datasets

56. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(What seems to work?)
SAVE-J study
Propensity Matching
ELSO
Risk Prediction
-Biomarkers
Organ Donation

57. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(What seems to work?)
SAVE-J study
Propensity Matching
ELSO
Risk Prediction
-Biomarkers
Organ Donation
Excellent prospective dataset
• Data rich
• Includes post cannulation data
(i.e. isn’t intended for case
selection)
Excellent performance (internal
validation)

58. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(What seems to work?)
SAVE-J study
Propensity Matching
ELSO
Risk Prediction
-Biomarkers
Organ Donation

59. The Alfred Intensive Care Unit, Melbourne, Australia
Outcomes from E-CPR
(What seems to work?)
SAVE-J study
Propensity Matching
ELSO
Risk Prediction
-Biomarkers
Organ Donation
Future Models are essential
1. Age
2. First monitored rhythm
3. Time to ECMO
4. Biomarkers (early lactate)
5. No/minimal physiological data

60. The Alfred Intensive Care Unit, Melbourne, Australia
Conclusions
E-CPR has strong physiological and evidence base to
support its use and ongoing development
Large database with accurate data to build risk
prediction models to assess performance
• allow better case selection
• allow comparison between services
• allow comparison between different treatments
Only one thing better than successfully treating a
cardiac arrest case with ECMO……

61. The Alfred Intensive Care Unit, Melbourne, Australia