CardiOhio Podcast
CardiOhio Podcast
ECPR: Something "Extra" to Improve Resuscitation Outcomes
Join our special guests, Drs. Kelsey Gray from Cleveland and Suzanne Bennett from Cincinnati, for a discussion on extracorporeal cardiopulmonary resuscitation (ECPR). We review the rationale for extracorporeal support during CPR, the components of a successful ECPR program, and discuss initial outcomes with the strategy.
For more information:
Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: A Meta-Analysis of Randomized Trials
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“Upbeat Party” by scottholmesmusic.com
So welcome back to the CardioOhio podcast. This is Canny Graywall in Columbus. Glad to have you back with us. And I'm also very happy to reintroduce my co host that most of you are familiar with, the current president of the Ohio ACC and imaging cardiologist in Cleveland at University Hospital, Dr. Ellen Savick. Welcome back.
Ellen:Canny. And today we actually have a fun topic on extracorporeal cardiopulmonary resuscitation and we are really lucky to have two specialists coming at the issue from sort of slightly different perspectives. We have Dr. Suzanne Bennett, who is professor of clinical section of anesthesiology. And she's medical director of the ICU and also director of the Anesthesia Critical Care Fellowship. And that is at University of Cincinnati College of Medicine. And we also have Dr. Kelsey Gray, who is a cardiothoracic surgeon at University Hospital's Cleveland Medical Center, assistant professor at Case Western Reserve University for the Department of Surgery. And both are heavily involved in their eCPR program. And we will learn a lot from them today.
Kanny:Yeah, thank you both for joining us. I just wanted to start by asking you both a little bit, we have a lot of fellows in training who listen to our podcast. So we always like to ask our guests a little about the pathway to their, current position and what made them get interested in their, in their current field. So I guess we can start with Kelsey obviously CT surgery, but what led you specifically to Cleveland specifically, and also having an interest in this topic?
Kelsey:Oh, that's a really good question. So I think many of the residents and fellows out there can relate to the nature of the match. So I did my general surgery residency in Los Angeles at Harbor UCLA. And there I was exposed to a fair amount of cardiac surgery and knew that that's what I wanted to pursue. So I applied and I matched here. At University Hospitals in Cleveland, and I got really, really lucky because I was very fortunate to come here right about the same time that this department was going through a big kind of evolution and growth and I've had the fortune, good fortune of working under a lot of really strong surgeons and. Great mentors who have exposed me to a lot of the things that I'm doing today 1 of the things that I've had the opportunity to get be really involved in here both in my fellowship here. And then I got hired and stayed on staff here is a heart failure and transplant. I do heart and lung transplant. And through that, I. I started having a very active role in our ECMO program and well, I guess almost four years ago now we started our ECPR program and I got to be involved in sort of the beginnings of that and some of that was just because I, Made a real estate choice that landed me very close to the hospital and that's basically what sort of kept me in a very active role as this program's evolved because 1 of the things necessary to have a successful program is to be able to get canulators. To the patients in the E. D. quickly. And so we don't have a ton of residents and fellows here right now with the way our program is set up that are on site. And so we've chosen our cannulators based on and kind of participants in this program based on their proximity to the hospital. So there's a handful of us that all live within about 5 to 10 minutes of the hospital, and we are kind of the primary players on the day to day basis for this program.
Kanny:Well, thanks. Sounds like quite a path. To get to you, H, which is my alma mater, by the way Suzanne with your background in anesthesia, when was it that you decided to focus on cardiac anesthesia? And then how did you specifically get interested in some of these, type treatments for cardiac patients.
Suzanne:You know, it's funny. my path is a little bit different than, than Dr. Grace and that I started as a nurse working in a, in ICU and it was a surgical and cardiac ICU recognizing that I was planning to go to medical school and fulfill my Dream of becoming a physician, which I did while working in the I. C. O. And I chose the pathway of anesthesiology knowing I was going to do critical care. As soon as I chose my residency in anesthesiology, it was really based on what critical care opportunities they afforded me. And I took the took my residency at the The, in the anesthesia department at University of Cincinnati, and they had a critical care fellowship at that time, did not have a link to any cardiac whatsoever, had no idea really I would land in a cardiac environment, you know, fast forward to finishing my fellowship in critical care and taking a job at the University of Cincinnati, UC Health health system I quickly, Became the medical director of the cardiac ICU there and the ECMO program, which started in 2014 and really found my love and, getting these sick patients. To opportunities that they didn't otherwise have available to them in the city. By the use of ECMO, we never, we, we, we delayed our start of the ECPR program until about 5 years ago, and actually launched it in March of 2020, which of course was. The goal time we targeted that time prior to knowing there was a pandemic upon us. However, we persevered and continued on with that and navigated those waters over the next couple of years as to when it was appropriate to continue that. And I was able to link my profession of anesthesiology, which I also dearly love with critical care and apply it to ECMO and, and all the different applications associated with it, including VA and VV and then of course, eCPR.
Ellen:Wonderful. So let's, let's get into the topic, Kelsey Dr. Gray, can you explain what is eCPR? How does that differ from routine ACLS for patients with out of hospital arrests and what are the benefits of this program? It's a lot to talk about.
Kelsey:I'll try and stay organized with my thoughts. So to start off, ECPR is basically ecmo CPR, and that's how you get the, kind of the letter acronym. So the, the tenants of ECPR are to basically capture patients who've had an out of hospital cardiac arrest who get to the hospital, are and are in a. a position to have survivability in terms of maybe having like a limited ischemic time, both to their brain and to their other organs, that would allow them to have recovery. But the problem is, is that they can't convert them into a I guess, perfusing rhythm. The patients that we're kind of funneling into this program are patients that have had a witnessed out of hospital cardiac arrest. Meaning, for example, we had a patient who was at a restaurant and had a witnessed heart attack and got bystander CPR and an ambulance got there, got them to the hospital and within about 30 minutes or so was in the er. Now this patient was getting high quality CPR all the way to the hospital. But, but Des, despite multiple rounds of ACL S, despite having a Lucas device doing good qua high quality chest compressions, this patient was not able to be converted into a sinus rhythm or any kind of perfusing rhythm for that matter. And so traditionally this, this. ACLS pathway would have you kind of continue until, you know, everybody agrees that proceeding is medically futile, or until there's some sort of perfusing rhythm. Now, if you get a perfusing rhythm after 45 minutes of CPR, I think we can all agree, even if it is high quality CPR, there's a pretty significant lack of blood flow, oxygenated blood to the brain, to the other organs, and a lot of these patients then never make a meaningful neurologic recovery. So eCPR has been designed to sort of intervene in that pathway. So you get to the hospital and at like that 20 minute mark or so, let's say, Of good high quality CPR, you still don't have a perfusing rhythm, then if you meet a certain, like, if you meet some certain metabolic parameters, which I think we can go over here in a little bit, then the decision point comes to start you on ECMO. So the patient's cannulated in the ER, placed onto ECMO, and as soon as the heart is decompressed, meaning as soon as the ECMO circuit starts to work, it's taking blood away from the right side of the heart, decompressing the heart, allowing the heart to kind of shrink back down and not become big and distended because it hasn't been able to eject. As soon as we're able to do that, and we're able to start circulating oxygenated blood, we see that a lot of times these patients within 30 minutes or so start to develop a perfusing sinus rhythm. So with that then and the support of the ECMO machine and this early intervention, we're also finding that these patients are doing a lot better overall. They're having better neurologic recovery because they're not, because they now have the ECMO circuit that's delivering good oxygenated blood to their brain, to their kidneys, to their livers, and they're not going into multi system and organ failure. They don't have as much, as high of risk of having like hypoxic neurologic injury and stuff like that. So these patients, we're taking patients that normally probably would have a pretty poor prognosis even if they did have return of a perfusing rhythm and we're taking them and we're turning them into patients that now have the ability to have meaning neurologic recovery and limited end organ failure while their heart recovers and is able to kind of either undergo stenting or treatment or whatever is necessary to sort of get them through their arrest. that was
Kanny:a great summary of of what, of what the treatment is. And and I think it leads to the next question for Suzanne, which is, Obviously, this is typically done at tertiary centers, but who are the components of your team that are required to provide this kind of advanced technique and, and how is that team activated when an eligible patient arrives?
Suzanne:So when you look at the different team models across the country you can find a little, little differences in each of the programs and how, how they've defined the team. But overall, the team makeup is very actually similar when you think of the principles that you're trying to achieve. I know some places have the cannulation done in the emergency room. Some do it in the cath lab, some choose to, you know, get them into an OR. or the hybrid OR would be another alternative. And so that will define what your team members are. At, at UC Health, University of Cincinnati, we, we have chosen a model where the activation occurs by our, for out of hospital arrest. It, it occurs with our EMS, our emergency medical services personnel, specifically the Cincinnati Fire Department. And they activate it, and it, it rings into our emergency room resuscitation area. That person then activates it in our in, in house communication system, and that Actually connects with our in house ECMO specialist, we have perfusionists who are at home our cardiac surgeons and our cath lab staff and our interventional cardiologists and then our critical care folks. And of course, all the other very important members of our team, which is nursing, nursing supervisor. That, that alarm, in our anesthesia department, that alarm goes out. We have a process in place that when they hit the emergency department, there's about five different important inclusion criteria that need to be identified. All of our EMS folks use the Lucas device, which Dr. Gray had mentioned earlier a mechanical CPR device. If we know the person's a candidate then we would quickly triage, less than five minutes, triage them to our hybrid suite or the designated interventional suite and the members that align there after we get through the emergency department where we have our critical care team members, which could be an anesthesiologist or emergency medicine doc on our team they work collaborative with the ER doc to identify candidacy, and then we quickly transport with our team members. CVSU charge nurse and some members of the emergency medicine team up to our hybrid suite We have our anesthesiology team, which could be made up of not only anesthesiologists, but residents or CRNAs And and then we have our ECMO specialist with our perfusionist driving in. Just like Dr. Gray referenced. We do have our cannulators coming in from home and we are fortunate enough to have our cardiac surgeons who all live within a. Less than 15 minute drive to the hospital and our intervention list have varying degrees of proximity to the institution, but it's all hands on deck. And whoever gets there, who has the most experience then would start the cannulation. And the leader of the code or the event is the critical care physician who's trying to ensure that. All of our standard work that we've identified that needs to be done is being done the conductor, let's say, of, of, of the, the team of people who are working together to try to save this patient and get them on full support ECMO, so it's a whole host of people and if one person is missing, it's palpable because everybody fulfills a role and this time sensitive emergency scenario.
Ellen:That's actually a great point. One question I had for you, and this might be a little bit different from one institution to the next, is once you get these people on support, they're on ECMO, what is the role, does everybody get left heart cath and PCI, who goes for CABG, once we're on support, what is the next step? And is there a specific protocol since time is of the essence for these patients?
Kelsey:Yeah, so we have a very specific protocol for our patients and how they kind of flow through their eCPR journey, if you will. So we have it very, very laid out from inclusion criteria to next steps. So we have three hard inclusion criteria. That patients must meet. They must meet two out of the three criteria to even be considered for cannulation. If you don't meet two out of the three, we can still make a group decision to cannulate, but then the patient is immediately bumped out of our E. C. P. R. Protocol. So the are hard criteria are a P. H. Greater than seven, a lactate less than or equal to 15 and an end title C. O. Two greater than 10. These are all markers of having high E. Quality chest compressions and high quality A. C. L. S. Prior to us intervening from ECMO standpoint after the decision has been made to cannulate, they get cannulated and where that happens. I think I agree. It just it varies from institution to institution for us. It happens in the E. R. We have a cooling protocol, so the next step is, is once they're on ECMO, they become, they start we start initiating our hypothermia protocol and cool them to 35 to 36 degrees via the ECMO circuit. We stop the mechanical CPR, and then the next step is once the ECMO cannulas are secured, these patients are immediately transferred to the cath lab. if they have a pathology that's suggestive of coronary artery disease, meaning they had a VT or VF arrest, which is one of the main criteria for getting included into eCPR, and they had EKG changes supportive of ischemia at the time that the, or if they've had EKG changes at any point in time supportive of ischemia. If we don't know the cause, they still go to the cath lab. So our protocol is very specific. It goes ER. cath lab. And in the cath lab, we also have a very protocolized approach. And this sort of, this came about through many meetings with our interventional cardiologists that we partnered very closely with in starting this program. Because we cannot do it without, like, we cannot do it without the whole team, right? And buy in from the whole team. So basically, the agreement that we reached is that every patient goes for a diagnostic angiogram. We do have some patients where it's very clear that there's some different pathology. And in those cases, we don't take them to the cath lab, and we can get into those kind of outliers more, but this is in general our protocol. And so they go to the cath lab and they get a diagnostic angiogram. Now, if on that cath there is a isolated proximal lesion in the LAD isolated left main, isolated proximal RCA, something that is a straightforward PCI, then the general agreement is is that that patient will undergo intervention for what is thought to be the culprit lesion. There's no extensive stenting. There's no multi vessel stenting. If there's no, if it's a complex lesion or multi vessel coronary disease or something that's a lot more complicated, we don't undertake it at that time. The patient remains on ECMO and is transferred from the cath lab. to the cardiac surgery ICU, where they kind of are, are managed medically from that point on. One, if it's a more complex PCI problem, and it's not something that's a like an easy, straightforward stent, then what we do is we wait for that patient to show kind of meaningful neurologic recovery, like reversal of any end organ. Dysfunction, anything that's going to give them, like, basically we need to have evidence of a good prognosis, and then at that point they'll go and they'll usually get some sort of PCI at that point.
Ellen:Wonderful. Dr. Bennett, is your protocol in your system set up similarly, or are there some certain differences at UC?
Suzanne:You know, it's actually very similar when it comes, when it comes to whether or not to intervene. I, you know, just stepping back a little bit, that initial criteria, which I think Dr. Gray had alluded to earlier was that, you know, to get cannulated, we looked at. The patient's they must have a witnessed cardiac arrest with immediate and by immediate, I mean, less than five minutes bystander CPR, a shockable rhythm and never being in a systole. And then, of course, an age, the age gets a little complicated because you often don't know the age of the patient, but you want to make sure that we know that the outcomes worsen after the age of 70. So That's one that takes a little bit more finesse and, and, and decision making after we've made the decision that they meet that criteria then the next step is very, I mean, it might even be the same Dr. Gray for we are in the process of cannulating, we get an arterial blood gas, if we don't have access to arterial, then we get a venous, but either way we get a blood gas that demonstrates that the lactate is less than 15. Your end tidal CO2 is greater than or equal to 10 millimeters of mercury. We also include a PaO2 of greater than or equal to 50 millimeters of mercury. And of course, going back to that very important rhythm, which has never had a systole. And at that point they go on ECMO. And, and what I've found is we cannulate, we get on full flow ECMO, we can breathe. At that point, we pause, and now we come together to discuss next steps for this patient. And if we believe this is a cardiac event that has driven the arrest we do exactly as Dr Gray outlined with, with relation to intervening on the culprit lesion. And, and, and the other thing that we didn't really talk about a little bit here is that You know, you get your two cannulas in. But we also wanna address distal limb ischemia, which we, we have to include in those discussions of timing when we ensure that, that the limb where we've cannula done, the arterial cannulation has adequate perfusion. And the we have chosen to adopt a distal li limb a distal perfusion cannula on all the limbs that we have in arterial cannula in. And how we do it really depends on the patient and their anatomy. Having said all that, I think just like she had alluded to, our decisions are focused around what's best for the patient and being malleable to those as opposed to having very, very strict protocol that may not be pertinent to what the patient needs.
Kanny:I just wanted to talk a little about, like, what specific outcomes We know from the evidence base are improved, with this therapy. I know a lot of the studies in the literature come from single centers. There are typically not a lot of, you know, high number of patients in the studies, because obviously it's a really challenging patient population to enroll in trials, and of course randomized trials are even more difficult.
Kelsey:So, yeah, this is a really great question. One of the most stark kind of visual representations of this that I've ever seen is in the circulation article that was published by Dr. I think it's Yiannopoulos and his team, and he's done a ton of work in this. And he has this is this incredible graphic that shows it maps the duration of CPR Over time and your rate of neurologically feasible survival and on this graph, you see this line at 10 minutes that you have 75 percent survival with traditional A. C. L. S. And by 30 minutes, you're down to less than 2 percent survival with traditional A. C. L. S. And now and then he maps that conversely with patients who've had E. C. P. R. And at 20 minutes, if you're cannulated and put on eCPR and you meet all these inclusion criteria that we kind of laid out, you'll have almost 100 percent neurologically favorable survival. Okay, now this isn't true survival to discharge from the hospital, right? There's a lot of hurdles to get over. This means that at 20 minutes, with eCPR, if you're cannulated at 20 minutes, you have almost nearing 100 percent neurologically favorable survival. And then At 40 to 45 minutes, you're still above a 50 percent chance of neurologically favorable survival. At one hour, you're still at 25 percent chance of neurologically favorable survival. And at 90 minutes, you're at about Like 15 to 20 percent of neurologically favorable survival. That means people are actually surviving at 90 minutes of high quality CPR and then getting placed on to ECMO. So this is, I think it's a really stark kind of breakdown of how beneficial eCPR can be when introduced appropriately into the ACLS algorithm. Now in terms of how that translates to hospital discharge I can share with you some of our results that we've had here and hopefully, Dr. Bennett, I know your program is kind of new, but I'm sure you're having similar outcomes because. Because of it's really the selection criteria for who gets cannulated that I think helps push us in this direction But we really do see that when you compare it to standard use of VA ECMO that we have a lot better survival, so Since we've started our program our overall ECPR survival is about very close like to 50% It's varied a little bit because our first few years we were still kind of learning who to say yes and no to But in 2024 our eCPR survival was 75 percent which is very good When you compare that to regular VA ECMO VA ECMO varies I think You know, kind of nationally, the average VA ECMO survival, and this is like survival to discharge is closer to about 30%, 30 to 45%, depending on institutions, some do a little better. Some do a little worse. It's all about kind of who you select and who you choose to put on. But when you compare that to eCPR, you see that these eCPR patients are really kind of the patients that are benefiting significantly from their runs on VA ECMO, and it's helping their overall survival. Wow, this is really impressive data.
Ellen:I mean, a lot of people out of hospital arrests really used to have dismal outcomes, but these are pretty impressive. So, Kelsey do we track our outcomes here at University Hospitals for all the patients who are in the program? And also, Dr. Bennett, do you track them at UC? And also, last question is, Is there a nationwide database for patients who are being treated with eCPR?
Kelsey:Yeah, so those numbers that I put up were mentioning were kind of like a summary of our numbers, like the 75 percent survival to discharge from 2024, the years prior, we were more in that 45 and then 50 percent range. But Dr. Bennett, how are you guys doing with your first few?
Suzanne:Yeah, so I It's, it's funny when we look at our program, we see that the program itself, not eCPR, but ECMO, we started in 2014, but didn't have a formal eCPR program till 2020. That time gap in between, we started submitting our data to ELSO. The extracorporeal life support organization that many centers are submitting their data to. It's a registry day based database. And any data we had between 2014 and 2020 is a little bit skewed for a couple of reasons. One, we didn't really have, had not adopted a formal program and the definition. Was more delineated after I think it was about 2016 through ELSO to include what ECPR is, which is that you have your, the patient is undergoing active CPR. Or ROSC within 20 minutes. Any time frame beyond that is not eCPR. However, having said that Kelsey, just like you had mentioned the Outcomes of ECPR are very selection based and and of course, cannulating strategies are extremely important as well. And we have similar outcomes as to what you have described. Our overall just overall all comers for ECMO survival that includes VV is. 65 percent but then when you break it down by ECMO, it gets a little bit different depending on why they were cannulated. But for eCPR alone, over the course of time, we've also been able to improve our survival to decannulation and, and, and Discharge to somewhere between 50 and 60%. And I, just like you had mentioned over the court over the course of the last couple of years, it feels as though the outcomes are just improving more and more with the fidelity of our team and our selection criteria, You asked about the database. Many of our centers do report our data to the, as I mentioned, the also registry. The benefit of that is you're able to benchmark yourself against like centers, whether that be based on volume or centers of excellence or, on academic versus not academic. And I found that to be extremely valuable and their database is even getting better and better, that you can actually they can generate a mortality, ODE. So the mortality observed versus expected. And very important point that Dr. Gray mentioned is that these patients prior to eCPR had conventional CPR and the outcomes were dismal. And with the Invention and application of E. C. P. R. Were able to improve their outcomes more than what they would have had available to them. And And as was mentioned before, it's very hard to have a, a prospective randomized control trial that's blinded, double blinded that we could have robust studies to support anything that we're doing, which is, I think, one of the major challenges in the adoption and acceptance of eCPR as a standard of care.
Kanny:Yeah, well, I'm glad to hear that. It sounds like as time goes on, we're going to be getting a lot more data and outcomes information to kind of guide implementation of this. We're kind of up against our time, but I did want to ask 1 final question to Kelsey. obviously, both of you are at. Large academic medical centers, two of the most prominent ones here in Ohio I guess my question is about how we extend this to other hospital settings where PCI is offered, but maybe they don't have all of the multidisciplinary resources Do you feel like, over time, this should be offered at any center that offers, you know, 24 hour PCI or at least has the resources to offer ECMO? And if so, you know, what are some of the barriers you think to implementing it more broadly?
Kelsey:Yeah, no, that's a really good question. And we've been toying with that here at because, you know We have a lot of regional hospitals that reach communities that if you have a out of hospital cardiac arrest, say, out like 30 miles from our main campus hospital here, It's very unlikely that paramedics are going to get to you, start ACLS, and get you to a center where you can have eCPR performed in a really truly timely fashion that makes it feasible. And so one of the things we've been looking at doing is expanding to one of our satellite hospitals, which is Illyria. And I think It's been in the works to do this, if not already approved. Now, we haven't started doing it yet, but this would be our first real run at doing it in a much more community based setting where the cardiac surgeons are not close and you would be relying very heavily on the cath lab. And other in hospital providers to do the cannulation. We do have a, like, a PERT team and that goes out there and they're most of those cardiologists are familiar with ECMO cannulation, but it's going to be a real undertaking in terms of training for us because we really are going to have to train staff to run an ECMO machine. You know, I think we're looking at training cath lab staff. very much. to run an ECMO machine. The perfusionists, you know, live quite a ways away from this hospital, so it's not really feasible to mobilize our whole team there like it is to do it centrally at our bigger hospital. So, things you have to take into account are, you know, who's going to run the ECMO machine until perfusion can arrive, and that's usually training we've trained our ER nurses here at our main campus to do it, and so I think looking at these smaller hospitals, you're looking at training, yeah. ER nurses, ER staff cath lab staff, cath lab nurses even cardiologists, how to kind of run the pump, get things set up, these sort of things, because you aren't going to have that, that core team that's normally responsible for doing ECMO there. So I think that's one of the biggest hurdles, one of the things that's being done by Dr. Yiannopoulos is that he has a mobile ECMO unit, so I think something like that may be another option for, these smaller communities that are further away, meaning, it gets activated out in the field and the It's a giant just basically mobile ECMO truck that drives and meets either at the hospital or at the site in the field and the patients actually put on ECMO in the, in the mobile ECMO unit. So I think there's a lot of creative things being done and people are sort of innovating in this field in terms of how to get it out to, Smaller communities or how to make it more accessible to people who live further away from these big tertiary care centers.
Ellen:Wow. This has been a very exciting discussion, and I think there's a whole lot more to come in the future. I really want to thank Drs. Gray and Drs. Bennett for sharing their expertise on this topic. We will have some links to the various articles, as well as some charts and some graphics, if people want to see sort of the setup and the outcomes. But I think for now, we're going to have to. Say thank you and we will see you all for future Cardio Ohio podcasts. Thank you. Thank you so much.
Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,
