ECMO for a Cardiac Arrest and Prolonged CPR in the Cath-Lab: Dose it worth? Case Report and Review of Literature-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY
Introduction: Nowadays the vast
expansion to ECMO indications raises ethical questions such as whose
patient should be treated with ECMO and when the ECMO support should be
discontinued?
Case presentation:57yr old gentleman
presented as ACS and 1yr PCI was planned. CAG revealed total occlusion
of LAD; LCX: mild lesions, RCA: totally occluded. Attempt to open the
RCA was failed, LAD was stented but after that he got CP arrest. CPR was
initiated and continued for 1.5h, then he revived, but echocardiography
showed EF 10%.
VA-ECMO was inserted then shifted to CCU and started
to be awake. CXR showed massive left pleural effusion so exploratory
thoracotomy was done which revealed big blood collection from
intercostal artery and fracture multiple ribs.
In 3rd day he was taken to the CathLab electively for
another trial to open the RCA which was successfully done. ECMO was
weaned off successfully in 5th day post implantation. Echocardiography
showed EF 40%.
Then he got aggressive chest infection and
septicemia. Hemodynamic deterioration increased so we re-implanted VA-
ECMO again after 48h from explantation for 2nd time and he again started
to improve.
In 3rd week he got massive hematemesis, melena and
upper GIT endoscopy revealed massive erosive gastritis. In 30th day post
cardiac arrest the oxygenator of the ECMO started to be clotted so ECMO
was explanted and he deteriorated and death was declared in next day.
Conclusion: Earlier and rapid
decision for ECMO is better and the question for starting ECMO in
cardiogenic-shock before PCI needs to be raised and validated. Bleeding
is the major risk of ECMO due to continuous infusion of heparin to
protect ECMO circuit.
Introduction and Background
Over the last several decades the scope of
applications of mechanical ventricular assisting devices has widened,
and the availability of easily deployable devices has increased
significantly [1]. The rapid adoptions of new temporary devices
necessitate physicians to become familiar with these commonly used
technologies [2].
Despite advances in coronary revascularization and
widespread use of primary percutaneous interventions, cardiogenic shock
complicating an acute ST-elevation myocardial infarction remains a
clinical challenge with high mortality rates [3]. Conservative
management with catecholamines is associated with serious limitations,
including arrhythmias, increased myocardial oxygen consumption, and
inadequate circulatory support [4,5]. Clinicians have therefore
turned to mechanical means of circulatory support. Circulatory
assist systems for cardiogenic shock complicating an acute STelevation
myocardial infarction can be distinguished by the
method of placement (i.e. percutaneous vs. surgical), the t ype
of circulatory support (i.e. left ventricular, right ventricular,
or biventricular), and whether they are combined with
extracorporal membrane oxygenation (ECMO) [6].
Extra Corporeal Membrane Oxygenation (ECMO) has
remarkably progressed over the recent years and became
a valuable tool in the care of patients with severe cardiac
and pulmonary dysfunction refractory to conventional
management [7]. Nowadays ECMO has become more reliable
with improvement in equipment, and increased experience,
which is reflected in improving results. The indications are
extended to more prolonged use in intensive care unit, such
as bridge to recovery, bridge to bridge or bridge to transplant,
for both cardiac and lung transplant and support for complex
cardiac and pulmonary procedures. The vast expansion to
its indications raises ethical questions such as whose patient
should be treated with ECMO and when the ECMO support
should be discontinued [7,8].
ECMO should only by performed by clinicians with good
training and experience. ECMO is a supportive therapy rather
than disease modifying treatment in itself; and the best results
are obtained if we chose the right patient, the right type of
ECMO and the right type of configuration (i.e. site, management
and complication anticipation) [9].
In this report we present our case who got a cardiac arrest
during primary PCI which necessitated prolonged CPR then
VA-ECMO deployment.
Our case is 57 years old gentleman, chronic heavy
smoker, recently discovered type 2 Diabetes Mellitus (DM),
hyperlipidemic, hypertensive and negative family history of
ischemic heart diseases. He presented to Emergency Room
(ER) with intermittent typical chest pain, associated with
sweating in the last 12 hours. Echocardiography showed
ejection fraction EF around 35% with multiple regional
wall motion abnormalities. He was hemodynamically stable
but has dynamic ECG changes; he was managed as a case of
acute coronary syndrome (ACS) and received a conventional
treatment and planned for urgent PCI next day. In the ward he
remained stable and asymptomatic for 6 hours after that he
experienced chest pain with new LBBB so he was shifted to
the Cath-lab for primary PCI. Coronary angiography revealed
proximal total occlusion of LAD; big ramus coronary artery with
tight long proximal lesion, LCX has non-flow limiting lesions,
RCA totally occluded as well with communicating collaterals
between LAD and some septal branches and RCA. Attempt to open the RCA was failed, so LAD was tried and the lesion was
crossed, ballooned and stented with small caliber artery distal
to the stent just after deployment of the stent, the patient went
into pulmonary edema, hypotension and bradycardia then
cardiopulmonary arrest. So cardiopulmonary resuscitation
(CPR) was initiated and intra aortic balloon counter-pulsation
(IABP) was inserted and temporary pace maker (TPM) was
placed and the patient was intubated and mechanically
ventilated. CPR was continuous for about one and half hours,
during this period Re-coronary angiography was performed.
The LAD was still open but the Ramus artery was sub-totally
occluded which was re-opened and stented successfully with
TIMI-3 flow. After that the patient revived but was on high
inotropic support and IABP, and echocardiography showed EF
around 10%. So the consensus of the cardiology and cardiac
surgery team was to place the patient on percutaneous VAECMO
and to give him the best chance for possible survival.
The family has been informed that the ECMO is the last resort
and if unsuccessful there are no other treatment options.
VA-ECMO was deployed in the left groin in the Cath-Lab
then the patient shifted to CCU and we could able to come down
with the inotropes and the patient started to be awake and
moving all limbs. In the first night the CVP was increased up
to 26mm H2O and CXR showed massive left pleural effusion so
left chest drain was inserted and more than 2 liters of bloody
effusion was drained after that the CVP went down to 11mm
H2O and the ABG improved but repeated Chest X-Ray revealed
recollection again in left pleura and his Hb continued dropping
despite of continuous blood transfusions so he was taken
to OR for exploratory left thoracotomy which revealed big
amount of blood clots and actively bleeding intercostal artery
and fracture ribs due to prolonged CPR with external cardiac
massage. After that he became stable again and Hb started to
build up.
After stabilization of the patient and became generally
better with good ABGs, and good hemodynamics he was taken
again to the Cath-Lab electively for another trial to open the
RCA which was succeeded this time and RCA was opened
and stented. The LAD and ramus artery’ stents were found
to be patent with TIMI-3 flow. The patient was shifted again
to CCU and ECMO weaning-off process started gradually
which was successfully done in the 5th day post implantation.
Echocardiography showed EF of 40%.
Post ECMO removal period was unremarkable and he
remained stable until after 36 hours from ECMO removal the
patient got sudden and rapid deterioration and he required
higher inotropes. Echocardiography showed global severe
hypokinesia and EF went down to be about 15%, so the decision
was to take him for emergency coronary angiography which
revealed that all coronary stents were occluded with fresh
thrombi, so percutaneous suction thrombectomy was done
from the three vessels (LAD, RCA and Ramus coronary artery)and IAB was inserted again in the Cath-lab. After that his
hemodynamic profile improved. Then we started to decrease
sedations to start weaning from the ventilator which failed
due to severe chest infection (ventilator acquired pneumonia
VAP) and flail chest due to bilateral multiple ribs and sternum
fractures after previous CPR, so bed-side percutaneous
tracheostomy was done.
The patient got progressive and aggressive infection
with +ve blood cultures and +ve sputum cultures as well
(acintobacter boumani, and pseudomonas carnii). Also he
required renal hemodialysis CRRT due to deteriorating kidney
function and high creatinine. Then he got a septic shock with
Hemodynamic deterioration and required more inotropes
again so after consensus the decision was to place him on 2nd
time VA-ECMO again. Percutaneous left femoral VA-ECMO was
inserted for 2nd time and the patient again started to improve
and Echocardiography showed an improvement in the cardiac
contractility as well with EF about 35%.
After few days the left leg (same side of ECMO) started to
be cold and pale despite there is shunt connection from the
arterial line to the femoral artery to supply the leg distal to
arterial cannula insertion. Vascular angiography revealed
clotted tibialis anterior artery so the ECMO was shifted to the
right side and open embolectomy to left tibialis anterior artery
was done using Fogarty catheter and the blood f low was good
again and the color of the leg improved and became warm but
the distal half of the foot did not improve and became cyanotic
and the process of dry gangrene started in the tips of the left
toes.
Trials of weaning from ECMO were done frequently but
were failed although he remained hemodynamically stable
until the 3rd week post cardiac arrest, the patient got massive
hematemesis and melena so, upper GIT endoscopy was done
and revealed massive erosive gastritis. In the 30th day post
cardiac arrest the oxygenator of the ECMO started to give poor
oxygination then started to be clotted so the decision was to
explant the ECMO device. After that the patient deteriorated
more and death was declared in next day from ECMO removal.
The percutaneous assist systems most commonly used in
cardiogenic shock MI are the intra-aortic balloon pump (IABP),
venoarterial ECMO, the Impella pump, and the Tandem-Heart.
Recently, the large randomized IABP-Shock II Trial did
not show a significant reduction in 30-day mortality in CSMI
with IABP insertion [10,11]. There are no randomized study
data available for ECMO use in CSMI. Both the Impella pump
and the Tandem-Heart did not reduce 30-day mortality when
compared with IABP in small randomized controlled trials
(RCTs). Despite the need for effective mechanical circulatory
support in CSMI, current devices, as tested, have not been demonstrated to improve short- or long-term survival rates
[12].
A meta-analysis by Cheng et al. [12] of 1,866 patients
receiving ECMO for treatment of cardiogenic shock and cardiac
arrest showed a survival to hospital discharge between 20.8-
65.4% [12,13].
Schmidt et al. [13] developed a survival calculator based on
analysis of 3,846 patients with refractory cardiogenic shock
treated with ECMO between 2003 and 2013 [14]. Improved
survival rates are associated with treatment of patients with
cardiogenic shock from myocarditis, refractory VT/VF or post
heart or lung transplantation. Other factors such as decreased
age significantly improve predicted survival particularly for
patients less than 63 years of age [14,15] and this was one of
the reasons to deploy the ECMO machine in our patient despite
of long time CPR because he was relatively young (57 years).
However, cardiogenic shock is not only a decrease in
cardiac contractile function, but also a multiorgan dysfunction
syndrome(MODS) resulting from peripheral hypoperfusion
with microcirculatory dysfunction, often complicated by a
systemic inflammatory response syndrome (SIRS) and sepsis.
Once MODS has developed, it is difficult to improve prognosis
and reduce mortality by simply increasing cardiac output with
a circulatory assist device [15], and this exactly what happened
in our case as it was complicated with sepsis and MODS as well.
Prevention of MODS may depend on three critical factors:
- Optimal timing (i.e. early initiation) of mechanical circulatory support.
- Optimal level of mechanical circulatory support with reestablishment of adequate perfusion of critical organs.
- Optimal prevention and management of potential device-related complications (i.e. device malfunction, infection) [15,16].
We have learned a lesson from this case that we must call
for ECMO in cases post witnessed cardiopulmonary arrest
within 10 minutes after the beginning of CPR, so we can put
the patient on ECMO earlier in a suitable time. We must put
in consideration that within 60 minutes from an effective CPR
the patient should be put on the ECMO machine (including
CPR+ECMO deployment time) and in our instate, we (as a
team from cardiac surgery, the cardiology, ER and anesthesia
department) have written an internal policy and protocol
for ECMO use including: post CPR in Cath-lab, in ER or any
department in the hospital and we initiated an “ECMO code
team” to be ready all the time “24\7” for any emergency once
it is indicated.
We confronted in the beginning with misconceptions
and they are common. Majority of our colleagues in other
departments “fear” the ECMO patient and misunderstand the roles of the team members involved in care of these patients.
The “fear” comes from ignorance and lack of experience and
leads to potential delays in referral and subsequent care and
this was what happen exactly in our case as the cath-lab team
consulted us for VA-ECMO lately after long time from the
beginning of CPR and this delay have worsened the outcome.
Earlier and rapid decision for ECMO insertion is better
and the question for starting ECMO in Cardiogenic shock
before PCI needs to be raised and validated for better patient
survival and good results. Collaboration between different
hospital departments must be there and is mandatory to build
up efficient ECMO service which can meet the needs for these
critically ill patients.
Bleeding is the major risk of the ECMO due to continuous
infusion of heparin to protect the ECMO circuit from clotting
and as in this case the balance between the risk of stent
thrombosis and bleeding was delicate with initial stent
thrombosis as a price to stop massive bleeding in the pleural
space and the GIT bleeding and erosive gastiritis as a price of
for keeping patent stents and ECMO circuits. CPR although life
saving but may result in rib fracture and continued bleeding
after ECMO which needs more attention to be done gently as
possible.
While ECMO may not be an optimal solution, it does
increase the survival in certain patient populations compared
to conventional treatment. ‘’Code ECMO’’ team should be
initiated from a cardiac surgery team and a perfusionist and
should be ready 24\7 to place the indicated patient on ECMO
for any respiratory or cardiac or cardiopulmonary failure.
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