ASAIO Q&A Summary | ECPR: Building the Team for Success

Do you have unanswered questions or underlying concerns regarding the discussion that took place during the ASAIO Journal and CTSNet webinar, “Extracorporeal Cardiopulmonary Resuscitation (ECPR): Building the Team for Success”? We’ve got you covered! For a total of 15 questions asked by the live audience, please refer to the below questions and answers that came up during the ASAIO Webinar, edited for length and clarity.

Webinar Recording

Question 1: Duke protocol states predicted low flow time < 60 min. Does that mean you are counting time of significant hypotension as part the consideration or just time of arrest? Are you routinely cooling patients after establishing ECMO flow?

• Dr. Keenan: If anything, we are becoming more stringent. Usually, you have limited information on specifics with patient history and arrest events when making the decision to cannulate.  We don’t necessarily consider pre-arrest hypotension in low flow calculation, but we are pushing for ECMO activation within 15 minutes from arrest because it will be 30-45 minutes from the time of activation to cannulation. We generally do not cool.

Question 2: Do you maintain a separate ECMO ICU facility or is it combined with routine cardiac ICU?

• Dr. Keenan: At Duke, VV ECMO patients can be managed in the MICU or CT surgery ICU.  VA ECMO patients are only managed in the CT surgery ICU.
• Dr. Slaughter and Dr. Kumar C.J.: ECMO patients are managed in the cardiac ICU.

Question 3: When do you decide to convert VA ECMO to LVAD?

• Dr. Keenan: Every situation is different, but usually we will attempt to address any underlying pathology that might provide means to native recovery and then give 48-72 hours of VA ECMO support before seriously evaluating whether the patient can wean off ECMO.  If the patient is unable to wean from ECMO to native recovery, you have to consider whether VAD or transplant is an option. If it potentially is, you then have to decide if the patient can be stepped down to another mode of temporary MCS, such as Impella 5.5 or an RVAD depending on mode of failure. Usually, there will be a benefit to tMCS bridge for reconditioning and addressing other acute illness before going to durable LVAD or transplant.

Question 4: If the patient did not regain consciousness after ECPR immediately, how do you decide the next step and LV unloading strategy?

• Dr. Keenan: If the patient does not wake up early on after ECPR, we will usually get a head CT to evaluate for hypoxic injury, consult neurology, and do an EEG. It is not always clear early on what the neurologic prognosis will be. If it is uncertain, I think it is appropriate to do what you can to promote native heart recovery pathway, which includes LV unloading as needed. You would not go down the durable MCS or transplant recovery pathway unless there is clear neurologic recovery.
• Dr. Kumar C.J.: Impella is the preferred LV unloading strategy for us.

Question 5: Do you rely completely on the cardiac surgical team for cannulation, or do you have cannulators outside the surgical team such as ED and/or critical care physicians/PAs?

• Dr. Keenan: In our system, cardiothoracic surgery does all the cannulation. VV ECMO patients can be managed in MICU or CT Surgery ICU. VA ECMO patients can only be cared for in the CT Surgery ICU. I am not certain if other models have been considered by decision makers.  Part of the challenge is connecting the cannulation event with subsequent care. At the systems level, how this is arranged, I think, is affected by local factors including staff makeup and resources.
• Dr. Kumar C.J.: The cardiac surgery team, mostly.

Question 6: In the immediate VA ECMO run with full support, do you titrate inotropes to pulse pressure?

• Dr. Keenan: I do. In general, I like to see around 15 mm Hg of pulse pressure as a minimum. If not achieving that, we definitely go forward with Impella.

Question 7: Who does ECMO system daily care in Duke? A perfusionist or ICU nurse?

• Dr. Keenan: We usually have a perfusionist in our CT surgery ICU to oversee daily ECMO system care. There are also ICU nurses or respiratory therapists who receive specialized training to become “ECMO specialists” who can also function to oversee daily ECMO system care. This is who usually oversees the system care in the MICU.

Question 8: How many out-of-hospital eCPR programs currently exist in the United States?

• Dr. Smith: I know of two, but I suspect there may be a few more.

Question 9: Would you use IABP to keep aortic valve opening if poor heart contractility after ECPR?

• Dr. Keenan: Yes, we sometimes use the IABP to assist with ventricular ejection during the VA ECMO support. Impellas are better for LV decompression, but sometimes IABP is enough if already in place, and sometimes there are reasons not to put an Impella (LV thrombus comes to mind).

Question 10: I have a question about defining the time of cardiac arrest. For example: a patient had a cardiac arrest at 12:00, achieved central pulse at 12:20, but less than 10 minutes had another cardiac arrest. The time for ECMO cannulation should be <60 minutes.

• Dr. Keenan: I don’t know if there is a right answer. The questions highlight how quickly you can get into a grey zone and why the decision to proceed or not proceed can be difficult. For me, if the patient has ROSC of 10 minutes—I would probably consider the second arrest as the “start-point” of low flow.

Question 11: Have you found when the LUCAS was in use, was there less patient movement to allow for easier cannulation and better ID of the vessels?

• Dr. Slaughter: For us, no. Pt motion seems to be more related to what type of bed they are on versus how the compression is applied.

Question 12: Did you see a higher mortality rate for those cannulated outside your ECMO center with your hub and spoke model?

• Dr. Kumar C.J.: Generally, yes.

Question 13: In the case of an institutional DCD procurement program, all PTs run ECPR to get potential further therapic chance even if it’s a different chapter, but to consider opinions/feelings?

• Dr. Smith: Totally agree.

Question 14: ECMELLA/ECPELLA transfemoral or transaxillary?

• Dr. Kumar C.J.: Depends on the anatomy.

Question 15: LV apical unloading vs. Impella?

• Dr. Smith: Apical unloading worries me in patients with already poor LV function. So I prefer Impella in that scenario or septostomy.

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