March 24, 2025 • 35 mins
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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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kanny (00:10):
So welcome back to the CardioOhio podcast.
This is Canny Graywall inColumbus.
Glad to have you back with us.
And I'm also very happy toreintroduce my co host that most
of you are familiar with, thecurrent president of the Ohio
ACC and imaging cardiologist inCleveland at University
Hospital, Dr.
(00:31):
Ellen Savick.
Welcome back.
Ellen (00:34):
Canny.
And today we actually have a funtopic on extracorporeal
cardiopulmonary resuscitationand we are really lucky to have
two specialists coming at theissue from sort of slightly
different perspectives.
We have Dr.
Suzanne Bennett, who isprofessor of clinical section of
anesthesiology.
And she's medical director ofthe ICU and also director of the
(00:56):
Anesthesia Critical CareFellowship.
And that is at University ofCincinnati College of Medicine.
And we also have Dr.
Kelsey Gray, who is acardiothoracic surgeon at
University Hospital's ClevelandMedical Center, assistant
professor at Case WesternReserve University for the
Department of Surgery.
And both are heavily involved intheir eCPR program.
(01:17):
And we will learn a lot fromthem today.
Kanny (01:20):
Yeah, thank you both for joining us.
I just wanted to start by askingyou both a little bit, we have a
lot of fellows in training wholisten to our podcast.
So we always like to ask ourguests a little about the
pathway to their, currentposition and what made them get
interested in their, in theircurrent field.
So I guess we can start withKelsey obviously CT surgery, but
(01:41):
what led you specifically toCleveland specifically, and also
having an interest in thistopic?
Kelsey (01:47):
Oh, that's a really good question.
So I think many of the residentsand fellows out there can relate
to the nature of the match.
So I did my general surgeryresidency in Los Angeles at
Harbor UCLA.
And there I was exposed to afair amount of cardiac surgery
and knew that that's what Iwanted to pursue.
(02:07):
So I applied and I matched here.
At University Hospitals inCleveland, and I got really,
really lucky because I was veryfortunate to come here right
about the same time that thisdepartment was going through a
big kind of evolution and growthand I've had the fortune, good
fortune of working under a lotof really strong surgeons and.
(02:28):
Great mentors who have exposedme to a lot of the things that
I'm doing today 1 of the thingsthat I've had the opportunity to
get be really involved in hereboth in my fellowship here.
And then I got hired and stayedon staff here is a heart failure
and transplant.
I do heart and lung transplant.
And through that, I.
I started having a very activerole in our ECMO program and
(02:51):
well, I guess almost four yearsago now we started our ECPR
program and I got to be involvedin sort of the beginnings of
that and some of that was justbecause I, Made a real estate
choice that landed me very closeto the hospital and that's
basically what sort of kept mein a very active role as this
(03:13):
program's evolved because 1 ofthe things necessary to have a
successful program is to be ableto get canulators.
To the patients in the E.
D.
quickly.
And so we don't have a ton ofresidents and fellows here right
now with the way our program isset up that are on site.
And so we've chosen ourcannulators based on and kind of
(03:35):
participants in this programbased on their proximity to the
hospital.
So there's a handful of us thatall live within about 5 to 10
minutes of the hospital, and weare kind of the primary players
on the day to day basis for thisprogram.
Kanny (03:47):
Well, thanks.
Sounds like quite a path.
To get to you, H, which is myalma mater, by the way Suzanne
with your background inanesthesia, when was it that you
decided to focus on cardiacanesthesia?
And then how did youspecifically get interested in
some of these, type treatmentsfor cardiac patients.
Suzanne (04:09):
You know, it's funny.
my path is a little bitdifferent than, than Dr.
Grace and that I started as anurse working in a, in ICU and
it was a surgical and cardiacICU recognizing that I was
planning to go to medical schooland fulfill my Dream of becoming
a physician, which I did whileworking in the I.
(04:31):
C.
O.
And I chose the pathway ofanesthesiology knowing I was
going to do critical care.
As soon as I chose my residencyin anesthesiology, it was really
based on what critical careopportunities they afforded me.
And I took the took my residencyat the The, in the anesthesia
department at University ofCincinnati, and they had a
(04:54):
critical care fellowship at thattime, did not have a link to any
cardiac whatsoever, had no ideareally I would land in a cardiac
environment, you know, fastforward to finishing my
fellowship in critical care andtaking a job at the University
of Cincinnati, UC Health healthsystem I quickly, Became the
(05:14):
medical director of the cardiacICU there and the ECMO program,
which started in 2014 and reallyfound my love and, getting these
sick patients.
To opportunities that theydidn't otherwise have available
to them in the city.
By the use of ECMO, we never,we, we, we delayed our start of
(05:36):
the ECPR program until about 5years ago, and actually launched
it in March of 2020, which ofcourse was.
The goal time we targeted thattime prior to knowing there was
a pandemic upon us.
However, we persevered andcontinued on with that and
navigated those waters over thenext couple of years as to when
(05:59):
it was appropriate to continuethat.
And I was able to link myprofession of anesthesiology,
which I also dearly love withcritical care and apply it to
ECMO and, and all the differentapplications associated with it,
including VA and VV and then ofcourse, eCPR.
Ellen (06:19):
Wonderful.
So let's, let's get into thetopic, Kelsey Dr.
Gray, can you explain what iseCPR?
How does that differ fromroutine ACLS for patients with
out of hospital arrests and whatare the benefits of this
program?
It's a lot to talk about.
Kelsey (06:38):
I'll try and stay organized with my thoughts.
So to start off, ECPR isbasically ecmo CPR, and that's
how you get the, kind of theletter acronym.
So the, the tenants of ECPR areto basically capture patients
who've had an out of hospitalcardiac arrest who get to the
(07:00):
hospital, are and are in a.
a position to have survivabilityin terms of maybe having like a
limited ischemic time, both totheir brain and to their other
organs, that would allow them tohave recovery.
But the problem is, is that theycan't convert them into a I
(07:23):
guess, perfusing rhythm.
The patients that we're kind offunneling into this program are
patients that have had awitnessed out of hospital
cardiac arrest.
Meaning, for example, we had apatient who was at a restaurant
and had a witnessed heart attackand got bystander CPR and an
ambulance got there, got them tothe hospital and within about 30
(07:45):
minutes or so was in the er.
Now this patient was gettinghigh quality CPR all the way to
the hospital.
But, but Des, despite multiplerounds of ACL S, despite having
a Lucas device doing good quahigh quality chest compressions,
this patient was not able to beconverted into a sinus rhythm or
(08:06):
any kind of perfusing rhythm forthat matter.
And so traditionally this, this.
ACLS pathway would have you kindof continue until, you know,
everybody agrees that proceedingis medically futile, or until
there's some sort of perfusingrhythm.
Now, if you get a perfusingrhythm after 45 minutes of CPR,
(08:27):
I think we can all agree, evenif it is high quality CPR,
there's a pretty significantlack of blood flow, oxygenated
blood to the brain, to the otherorgans, and a lot of these
patients then never make ameaningful neurologic recovery.
So eCPR has been designed tosort of intervene in that
pathway.
So you get to the hospital andat like that 20 minute mark or
(08:50):
so, let's say, Of good highquality CPR, you still don't
have a perfusing rhythm, then ifyou meet a certain, like, if you
meet some certain metabolicparameters, 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 inthe ER, placed onto ECMO, and as
(09:14):
soon as the heart isdecompressed, 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 ofshrink back down and not become
big and distended because ithasn't been able to eject.
As soon as we're able to dothat, and we're able to start
circulating oxygenated blood, wesee that a lot of times these
(09:35):
patients within 30 minutes or sostart to develop a perfusing
sinus rhythm.
So with that then and thesupport of the ECMO machine and
this early intervention, we'realso finding that these patients
are doing a lot better overall.
They're having better neurologicrecovery because they're not,
because they now have the ECMOcircuit that's delivering good
(09:59):
oxygenated blood to their brain,to their kidneys, to their
livers, and they're not goinginto multi system and organ
failure.
They don't have as much, as highof risk of having like hypoxic
neurologic injury and stuff likethat.
So these patients, we're takingpatients that normally probably
would have a pretty poorprognosis even if they did have
return of a perfusing rhythm andwe're taking them and we're
(10:20):
turning them into patients thatnow have the ability to have
meaning neurologic recovery andlimited end organ failure while
their heart recovers and is ableto kind of either undergo
stenting or treatment orwhatever is necessary to sort of
get them through their arrest.
that was
Kanny (10:37):
a great summary of of what, of what the treatment is.
And and I think it leads to thenext question for Suzanne, which
is, Obviously, this is typicallydone at tertiary centers, but
who are the components of yourteam that are required to
provide this kind of advancedtechnique and, and how is that
team activated when an eligiblepatient arrives?
Suzanne (10:58):
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, howthey've defined the team.
But overall, the team makeup isvery actually similar when you
think of the principles thatyou're trying to achieve.
(11:19):
I know some places have thecannulation done in the
emergency room.
Some do it in the cath lab, somechoose to, you know, get them
into an OR.
or the hybrid OR would beanother alternative.
And so that will define whatyour team members are.
At, at UC Health, University ofCincinnati, we, we have chosen a
(11:43):
model where the activationoccurs by our, for out of
hospital arrest.
It, it occurs with our EMS, ouremergency medical services
personnel, specifically theCincinnati Fire Department.
And they activate it, and it, itrings into our emergency room
(12:04):
resuscitation area.
That person then activates it inour in, in house communication
system, and that Actuallyconnects with our in house ECMO
specialist, we haveperfusionists who are at home
our cardiac surgeons and ourcath lab staff and our
(12:27):
interventional cardiologists andthen our critical care folks.
And of course, all the othervery important members of our
team, which is nursing, nursingsupervisor.
That, that alarm, in ouranesthesia department, that
alarm goes out.
We have a process in place thatwhen they hit the emergency
department, there's about fivedifferent important inclusion
(12:47):
criteria that need to beidentified.
All of our EMS folks use theLucas device, which Dr.
Gray had mentioned earlier amechanical CPR device.
If we know the person's acandidate then we would quickly
triage, less than five minutes,triage them to our hybrid suite
(13:09):
or the designated interventionalsuite and the members that align
there after we get through theemergency department where we
have our critical care teammembers, which could be an
anesthesiologist or emergencymedicine doc on our team they
work collaborative with the ERdoc to identify candidacy, and
then we quickly transport withour team members.
(13:31):
CVSU charge nurse and somemembers of the emergency
medicine team up to our hybridsuite We have our anesthesiology
team, which could be made up ofnot only anesthesiologists, but
residents or CRNAs And and thenwe have our ECMO specialist with
our perfusionist driving in.
Just like Dr.
Gray referenced.
(13:51):
We do have our cannulatorscoming in from home and we are
fortunate enough to have ourcardiac surgeons who all live
within a.
Less than 15 minute drive to thehospital and our intervention
list have varying degrees ofproximity to the institution,
but it's all hands on deck.
(14:12):
And whoever gets there, who hasthe most experience then would
start the cannulation.
And the leader of the code orthe event is the critical care
physician who's trying to ensurethat.
All of our standard work thatwe've identified that needs to
be done is being done theconductor, let's say, of, of, of
(14:35):
the, the team of people who areworking together to try to save
this patient and get them onfull support ECMO, so it's a
whole host of people and if oneperson is missing, it's palpable
because everybody fulfills arole and this time sensitive
emergency scenario.
Ellen (14:57):
That's actually a great point.
One question I had for you, andthis might be a little bit
different from one institutionto the next, is once you get
these people on support, they'reon ECMO, what is the role, does
everybody get left heart cathand PCI, who goes for CABG, once
we're on support, what is thenext step?
(15:17):
And is there a specific protocolsince time is of the essence for
these patients?
Kelsey (15:21):
Yeah, so we have a very specific protocol for our
patients and how they kind offlow through their eCPR journey,
if you will.
So we have it very, very laidout from inclusion criteria to
next steps.
So we have three hard inclusioncriteria.
That patients must meet.
(15:43):
They must meet two out of thethree criteria to even be
considered for cannulation.
If you don't meet two out of thethree, we can still make a group
decision to cannulate, but thenthe patient is immediately
bumped out of our E.
C.
P.
R.
Protocol.
So the are hard criteria are aP.
H.
Greater than seven, a lactateless than or equal to 15 and an
(16:03):
end title C.
O.
Two greater than 10.
These are all markers of havinghigh E.
Quality chest compressions andhigh quality A.
C.
L.
S.
Prior to us intervening fromECMO standpoint after the
decision has been made tocannulate, they get cannulated
and where that happens.
I think I agree.
It just it varies frominstitution to institution for
us.
It happens in the E.
R.
(16:25):
We have a cooling protocol, sothe next step is, is once
they're on ECMO, they become,they start we start initiating
our hypothermia protocol andcool them to 35 to 36 degrees
via the ECMO circuit.
We stop the mechanical CPR, andthen the next step is once the
ECMO cannulas are secured, thesepatients are immediately
transferred to the cath lab.
(16:46):
if they have a pathology that'ssuggestive of coronary artery
disease, meaning they had a VTor VF arrest, which is one of
the main criteria for gettingincluded into eCPR, and they had
EKG changes supportive ofischemia at the time that the,
or if they've had EKG changes atany point in time supportive of
(17:07):
ischemia.
If we don't know the cause, theystill go to the cath lab.
So our protocol is veryspecific.
It goes ER.
cath lab.
And in the cath lab, we alsohave a very protocolized
approach.
And this sort of, this cameabout through many meetings with
our interventional cardiologiststhat we partnered very closely
with in starting this program.
(17:27):
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 thatwe reached is that every patient
goes for a diagnostic angiogram.
We do have some patients whereit's very clear that there's
some different pathology.
And in those cases, we don'ttake them to the cath lab, and
(17:47):
we can get into those kind ofoutliers more, but this is in
general our protocol.
And so they go to the cath laband they get a diagnostic
angiogram.
Now, if on that cath there is aisolated proximal lesion in the
LAD isolated left main, isolatedproximal RCA, something that is
(18:07):
a straightforward PCI, then thegeneral agreement is is that
that patient will undergointervention for what is thought
to be the culprit lesion.
There's no extensive stenting.
There's no multi vesselstenting.
If there's no, if it's a complexlesion or multi vessel coronary
disease or something that's alot more complicated, we don't
(18:28):
undertake it at that time.
The patient remains on ECMO andis transferred from the cath
lab.
to the cardiac surgery ICU,where they kind of are, are
managed medically from thatpoint on.
One, if it's a more complex PCIproblem, and it's not something
that's a like an easy,straightforward stent, then what
we do is we wait for thatpatient to show kind of
(18:49):
meaningful neurologic recovery,like reversal of any end organ.
Dysfunction, anything that'sgoing to give them, like,
basically we need to haveevidence of a good prognosis,
and then at that point they'llgo and they'll usually get some
sort of PCI at that point.
Ellen (19:07):
Wonderful.
Dr.
Bennett, is your protocol inyour system set up similarly, or
are there some certaindifferences at UC?
Suzanne (19:17):
You know, it's actually very similar when it comes, when
it comes to whether or not tointervene.
I, you know, just stepping backa little bit, that initial
criteria, which I think Dr.
Gray had alluded to earlier wasthat, you know, to get
cannulated, we looked at.
The patient's they must have awitnessed cardiac arrest with
(19:40):
immediate and by immediate, Imean, less than five minutes
bystander CPR, a shockablerhythm and never being in a
systole.
And then, of course, an age, theage gets a little complicated
because you often don't know theage of the patient, but you want
to make sure that we know thatthe outcomes worsen after the
(20:03):
age of 70.
So That's one that takes alittle bit more finesse and,
and, and decision making afterwe've made the decision that
they meet that criteria then thenext step is very, I mean, it
might even be the same Dr.
Gray for we are in the processof cannulating, we get an
(20:25):
arterial blood gas, if we don'thave access to arterial, then we
get a venous, but either way weget a blood gas that
demonstrates that the lactate isless than 15.
Your end tidal CO2 is greaterthan or equal to 10 millimeters
of mercury.
We also include a PaO2 ofgreater than or equal to 50
millimeters of mercury.
And of course, going back tothat very important rhythm,
(20:46):
which has never had a systole.
And at that point they go onECMO.
And, and what I've found is wecannulate, we get on full flow
ECMO, we can breathe.
At that point, we pause, and nowwe come together to discuss next
steps for this patient.
And if we believe this is acardiac event that has driven
(21:10):
the arrest we do exactly as DrGray outlined with, with
relation to intervening on theculprit lesion.
And, and, and the other thingthat we didn't really talk about
a little bit here is that Youknow, you get your two cannulas
in.
But we also wanna address distallimb ischemia, which we, we have
(21:31):
to include in those discussionsof timing when we ensure that,
that the limb where we'vecannula done, the arterial
cannulation has adequateperfusion.
And the we have chosen to adopta distal li limb a distal
perfusion cannula on all thelimbs that we have in arterial
cannula in.
(21:52):
And how we do it really dependson the patient and their
anatomy.
Having said all that, I thinkjust like she had alluded to,
our decisions are focused aroundwhat's best for the patient and
being malleable to those asopposed to having very, very
strict protocol that may not bepertinent to what the patient
needs.
Kanny (22:12):
I just wanted to talk a little about, like, what
specific outcomes We know fromthe evidence base are improved,
with this therapy.
I know a lot of the studies inthe literature come from single
centers.
There are typically not a lotof, you know, high number of
patients in the studies, becauseobviously it's a really
challenging patient populationto enroll in trials, and of
(22:33):
course randomized trials areeven more difficult.
Kelsey (22:36):
So, yeah, this is a really great question.
One of the most stark kind ofvisual representations of this
that I've ever seen is in thecirculation article that was
published by Dr.
I think it's Yiannopoulos andhis team, and he's done a ton of
work in this.
And he has this is thisincredible graphic that shows it
maps the duration of CPR Overtime and your rate of
(23:01):
neurologically feasible survivaland on this graph, you see this
line at 10 minutes that you have75 percent survival with
traditional A.
C.
L.
S.
And by 30 minutes, you're downto less than 2 percent survival
with traditional A.
C.
L.
S.
And now and then he maps thatconversely with patients who've
had E.
C.
P.
R.
(23:21):
And at 20 minutes, if you'recannulated and put on eCPR and
you meet all these inclusioncriteria that we kind of laid
out, you'll have almost 100percent neurologically favorable
survival.
Okay, now this isn't truesurvival to discharge from the
hospital, right?
There's a lot of hurdles to getover.
This means that at 20 minutes,with eCPR, if you're cannulated
(23:44):
at 20 minutes, you have almostnearing 100 percent
neurologically favorablesurvival.
And then At 40 to 45 minutes,you're still above a 50 percent
chance of neurologicallyfavorable survival.
At one hour, you're still at 25percent chance of neurologically
favorable survival.
And at 90 minutes, you're atabout Like 15 to 20 percent of
(24:09):
neurologically favorablesurvival.
That means people are actuallysurviving at 90 minutes of high
quality CPR and then gettingplaced on to ECMO.
So this is, I think it's areally stark kind of breakdown
of how beneficial eCPR can bewhen introduced appropriately
into the ACLS algorithm.
(24:29):
Now in terms of how thattranslates to hospital discharge
I can share with you some of ourresults that we've had here and
hopefully, Dr.
Bennett, I know your program iskind of new, but I'm sure you're
having similar outcomes because.
Because of it's really theselection criteria for who gets
cannulated that I think helpspush us in this direction But we
(24:53):
really do see that when youcompare it to standard use of VA
ECMO that we have a lot bettersurvival, so Since we've started
our program our overall ECPRsurvival is about very close
like to 50% It's varied a littlebit because our first few years
we were still kind of learningwho to say yes and no to But in
(25:15):
2024 our eCPR survival was 75percent which is very good When
you compare that to regular VAECMO VA ECMO varies I think You
know, kind of nationally, theaverage VA ECMO survival, and
this is like survival todischarge is closer to about
(25:38):
30%, 30 to 45%, depending oninstitutions, some do a little
better.
Some do a little worse.
It's all about kind of who youselect and who you choose to put
on.
But when you compare that toeCPR, you see that these eCPR
patients are really kind of thepatients that are benefiting
significantly from their runs onVA ECMO, and it's helping their
(26:00):
overall survival.
Wow, this is really impressivedata.
Ellen (26:04):
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 ouroutcomes here at University
Hospitals for all the patientswho are in the program?
And also, Dr.
Bennett, do you track them atUC?
And also, last question is, Isthere a nationwide database for
(26:28):
patients who are being treatedwith eCPR?
Kelsey (26:33):
Yeah, so those numbers that I put up were mentioning
were kind of like a summary ofour numbers, like the 75 percent
survival to discharge from 2024,the years prior, we were more in
that 45 and then 50 percentrange.
But Dr.
Bennett, how are you guys doingwith your first few?
Suzanne (26:55):
Yeah, so I It's, it's funny when we look at our
program, we see that the programitself, not eCPR, but ECMO, we
started in 2014, but didn't havea formal eCPR program till 2020.
That time gap in between, westarted submitting our data to
ELSO.
The extracorporeal life supportorganization that many centers
(27:22):
are submitting their data to.
It's a registry day baseddatabase.
And any data we had between 2014and 2020 is a little bit skewed
for a couple of reasons.
One, we didn't really have, hadnot adopted a formal program and
the definition.
Was more delineated after Ithink it was about 2016 through
(27:44):
ELSO to include what ECPR is,which is that you have your, the
patient is undergoing activeCPR.
Or ROSC within 20 minutes.
Any time frame beyond that isnot eCPR.
However, having said thatKelsey, just like you had
mentioned the Outcomes of ECPRare very selection based and and
(28:11):
of course, cannulatingstrategies are extremely
important as well.
And we have similar outcomes asto what you have described.
Our overall just overall allcomers for ECMO survival that
includes VV is.
65 percent but then when youbreak it down by ECMO, it gets a
(28:36):
little bit different dependingon why they were cannulated.
But for eCPR alone, over thecourse of time, we've also been
able to improve our survival todecannulation and, and, and
Discharge to somewhere between50 and 60%.
And I, just like you hadmentioned over the court over
(28:58):
the course of the last couple ofyears, it feels as though the
outcomes are just improving moreand more with the fidelity of
our team and our selectioncriteria, You asked about the
database.
Many of our centers do reportour data to the, as I mentioned,
the also registry.
(29:19):
The benefit of that is you'reable to benchmark yourself
against like centers, whetherthat be based on volume or
centers of excellence or, onacademic versus not academic.
And I found that to be extremelyvaluable and their database is
even getting better and better,that you can actually they can
(29:42):
generate a mortality, ODE.
So the mortality observed versusexpected.
And very important point thatDr.
Gray mentioned is that thesepatients prior to eCPR had
conventional CPR and theoutcomes were dismal.
And with the Invention andapplication of E.
(30:04):
C.
P.
R.
Were able to improve theiroutcomes more than what they
would have had available tothem.
And And as was mentioned before,it's very hard to have a, a
prospective randomized controltrial that's blinded, double
blinded that we could haverobust studies to support
(30:28):
anything that we're doing, whichis, I think, one of the major
challenges in the adoption andacceptance of eCPR as a standard
of care.
Kanny (30:37):
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 outcomesinformation to kind of guide
implementation of this.
We're kind of up against ourtime, 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
(30:59):
here in Ohio I guess my questionis about how we extend this to
other hospital settings wherePCI is offered, but maybe they
don't have all of themultidisciplinary resources Do
you feel like, over time, thisshould be offered at any center
that offers, you know, 24 hourPCI or at least has the
(31:22):
resources to offer ECMO?
And if so, you know, what aresome of the barriers you think
to implementing it more broadly?
Kelsey (31:30):
Yeah, no, that's a really good question.
And we've been toying with thathere at because, you know We
have a lot of regional hospitalsthat reach communities that if
you have a out of hospitalcardiac arrest, say, out like 30
miles from our main campushospital here, It's very
(31:51):
unlikely that paramedics aregoing to get to you, start ACLS,
and get you to a center whereyou can have eCPR performed in a
really truly timely fashion thatmakes it feasible.
And so one of the things we'vebeen looking at doing is
expanding to one of oursatellite hospitals, which is
Illyria.
And I think It's been in theworks to do this, if not already
approved.
(32:12):
Now, we haven't started doing ityet, but this would be our first
real run at doing it in a muchmore community based setting
where the cardiac surgeons arenot close and you would be
relying very heavily on the cathlab.
And other in hospital providersto do the cannulation.
We do have a, like, a PERT teamand that goes out there and
(32:34):
they're most of thosecardiologists are familiar with
ECMO cannulation, but it's goingto be a real undertaking in
terms of training for us becausewe really are going to have to
train staff to run an ECMOmachine.
You know, I think we're lookingat training cath lab staff.
very much.
to run an ECMO machine.
(32:54):
The perfusionists, you know,live quite a ways away from this
hospital, so it's not reallyfeasible to mobilize our whole
team there like it is to do itcentrally at our bigger
hospital.
So, things you have to take intoaccount are, you know, who's
going to run the ECMO machineuntil perfusion can arrive, and
that's usually training we'vetrained our ER nurses here at
(33:14):
our main campus to do it, and soI think looking at these smaller
hospitals, you're looking attraining, yeah.
ER nurses, ER staff cath labstaff, cath lab nurses even
cardiologists, how to kind ofrun the pump, get things set up,
these sort of things, becauseyou aren't going to have that,
that core team that's normallyresponsible for doing ECMO
(33:36):
there.
So I think that's one of thebiggest hurdles, one of the
things that's being done by Dr.
Yiannopoulos is that he has amobile ECMO unit, so I think
something like that may beanother option for, these
smaller communities that arefurther away, meaning, it gets
(33:57):
activated out in the field andthe It's a giant just basically
mobile ECMO truck that drivesand meets either at the hospital
or at the site in the field andthe patients actually put on
ECMO in the, in the mobile ECMOunit.
So I think there's a lot ofcreative things being done and
people are sort of innovating inthis field in terms of how to
(34:20):
get it out to, Smallercommunities or how to make it
more accessible to people wholive further away from these big
tertiary care centers.
Ellen (34:28):
Wow.
This has been a very excitingdiscussion, and I think there's
a whole lot more to come in thefuture.
I really want to thank Drs.
Gray and Drs.
Bennett for sharing theirexpertise on this topic.
We will have some links to thevarious articles, as well as
some charts and some graphics,if people want to see sort of
(34:49):
the setup and the outcomes.
But I think for now, we're goingto have to.
Say thank you and we will seeyou all for future Cardio Ohio
podcasts.
Thank you.
Thank you so much.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
So welcome back to the CardioOhio podcast.
This is Canny Graywall inColumbus.
Glad to have you back with us.
And I'm also very happy toreintroduce my co host that most
of you are familiar with, thecurrent president of the Ohio
ACC and imaging cardiologist inCleveland at University
Hospital, Dr.
(00:31):
Ellen Savick.
Welcome back.
Ellen (00:34):
Canny.
And today we actually have a funtopic on extracorporeal
cardiopulmonary resuscitationand we are really lucky to have
two specialists coming at theissue from sort of slightly
different perspectives.
We have Dr.
Suzanne Bennett, who isprofessor of clinical section of
anesthesiology.
And she's medical director ofthe ICU and also director of the
(00:56):
Anesthesia Critical CareFellowship.
And that is at University ofCincinnati College of Medicine.
And we also have Dr.
Kelsey Gray, who is acardiothoracic surgeon at
University Hospital's ClevelandMedical Center, assistant
professor at Case WesternReserve University for the
Department of Surgery.
And both are heavily involved intheir eCPR program.
(01:17):
And we will learn a lot fromthem today.
Kanny (01:20):
Yeah, thank you both for joining us.
I just wanted to start by askingyou both a little bit, we have a
lot of fellows in training wholisten to our podcast.
So we always like to ask ourguests a little about the
pathway to their, currentposition and what made them get
interested in their, in theircurrent field.
So I guess we can start withKelsey obviously CT surgery, but
(01:41):
what led you specifically toCleveland specifically, and also
having an interest in thistopic?
Kelsey (01:47):
Oh, that's a really good question.
So I think many of the residentsand fellows out there can relate
to the nature of the match.
So I did my general surgeryresidency in Los Angeles at
Harbor UCLA.
And there I was exposed to afair amount of cardiac surgery
and knew that that's what Iwanted to pursue.
(02:07):
So I applied and I matched here.
At University Hospitals inCleveland, and I got really,
really lucky because I was veryfortunate to come here right
about the same time that thisdepartment was going through a
big kind of evolution and growthand I've had the fortune, good
fortune of working under a lotof really strong surgeons and.
(02:28):
Great mentors who have exposedme to a lot of the things that
I'm doing today 1 of the thingsthat I've had the opportunity to
get be really involved in hereboth in my fellowship here.
And then I got hired and stayedon staff here is a heart failure
and transplant.
I do heart and lung transplant.
And through that, I.
I started having a very activerole in our ECMO program and
(02:51):
well, I guess almost four yearsago now we started our ECPR
program and I got to be involvedin sort of the beginnings of
that and some of that was justbecause I, Made a real estate
choice that landed me very closeto the hospital and that's
basically what sort of kept mein a very active role as this
(03:13):
program's evolved because 1 ofthe things necessary to have a
successful program is to be ableto get canulators.
To the patients in the E.
D.
quickly.
And so we don't have a ton ofresidents and fellows here right
now with the way our program isset up that are on site.
And so we've chosen ourcannulators based on and kind of
(03:35):
participants in this programbased on their proximity to the
hospital.
So there's a handful of us thatall live within about 5 to 10
minutes of the hospital, and weare kind of the primary players
on the day to day basis for thisprogram.
Kanny (03:47):
Well, thanks.
Sounds like quite a path.
To get to you, H, which is myalma mater, by the way Suzanne
with your background inanesthesia, when was it that you
decided to focus on cardiacanesthesia?
And then how did youspecifically get interested in
some of these, type treatmentsfor cardiac patients.
Suzanne (04:09):
You know, it's funny.
my path is a little bitdifferent than, than Dr.
Grace and that I started as anurse working in a, in ICU and
it was a surgical and cardiacICU recognizing that I was
planning to go to medical schooland fulfill my Dream of becoming
a physician, which I did whileworking in the I.
(04:31):
C.
O.
And I chose the pathway ofanesthesiology knowing I was
going to do critical care.
As soon as I chose my residencyin anesthesiology, it was really
based on what critical careopportunities they afforded me.
And I took the took my residencyat the The, in the anesthesia
department at University ofCincinnati, and they had a
(04:54):
critical care fellowship at thattime, did not have a link to any
cardiac whatsoever, had no ideareally I would land in a cardiac
environment, you know, fastforward to finishing my
fellowship in critical care andtaking a job at the University
of Cincinnati, UC Health healthsystem I quickly, Became the
(05:14):
medical director of the cardiacICU there and the ECMO program,
which started in 2014 and reallyfound my love and, getting these
sick patients.
To opportunities that theydidn't otherwise have available
to them in the city.
By the use of ECMO, we never,we, we, we delayed our start of
(05:36):
the ECPR program until about 5years ago, and actually launched
it in March of 2020, which ofcourse was.
The goal time we targeted thattime prior to knowing there was
a pandemic upon us.
However, we persevered andcontinued on with that and
navigated those waters over thenext couple of years as to when
(05:59):
it was appropriate to continuethat.
And I was able to link myprofession of anesthesiology,
which I also dearly love withcritical care and apply it to
ECMO and, and all the differentapplications associated with it,
including VA and VV and then ofcourse, eCPR.
Ellen (06:19):
Wonderful.
So let's, let's get into thetopic, Kelsey Dr.
Gray, can you explain what iseCPR?
How does that differ fromroutine ACLS for patients with
out of hospital arrests and whatare the benefits of this
program?
It's a lot to talk about.
Kelsey (06:38):
I'll try and stay organized with my thoughts.
So to start off, ECPR isbasically ecmo CPR, and that's
how you get the, kind of theletter acronym.
So the, the tenants of ECPR areto basically capture patients
who've had an out of hospitalcardiac arrest who get to the
(07:00):
hospital, are and are in a.
a position to have survivabilityin terms of maybe having like a
limited ischemic time, both totheir brain and to their other
organs, that would allow them tohave recovery.
But the problem is, is that theycan't convert them into a I
(07:23):
guess, perfusing rhythm.
The patients that we're kind offunneling into this program are
patients that have had awitnessed out of hospital
cardiac arrest.
Meaning, for example, we had apatient who was at a restaurant
and had a witnessed heart attackand got bystander CPR and an
ambulance got there, got them tothe hospital and within about 30
(07:45):
minutes or so was in the er.
Now this patient was gettinghigh quality CPR all the way to
the hospital.
But, but Des, despite multiplerounds of ACL S, despite having
a Lucas device doing good quahigh quality chest compressions,
this patient was not able to beconverted into a sinus rhythm or
(08:06):
any kind of perfusing rhythm forthat matter.
And so traditionally this, this.
ACLS pathway would have you kindof continue until, you know,
everybody agrees that proceedingis medically futile, or until
there's some sort of perfusingrhythm.
Now, if you get a perfusingrhythm after 45 minutes of CPR,
(08:27):
I think we can all agree, evenif it is high quality CPR,
there's a pretty significantlack of blood flow, oxygenated
blood to the brain, to the otherorgans, and a lot of these
patients then never make ameaningful neurologic recovery.
So eCPR has been designed tosort of intervene in that
pathway.
So you get to the hospital andat like that 20 minute mark or
(08:50):
so, let's say, Of good highquality CPR, you still don't
have a perfusing rhythm, then ifyou meet a certain, like, if you
meet some certain metabolicparameters, 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 inthe ER, placed onto ECMO, and as
(09:14):
soon as the heart isdecompressed, 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 ofshrink back down and not become
big and distended because ithasn't been able to eject.
As soon as we're able to dothat, and we're able to start
circulating oxygenated blood, wesee that a lot of times these
(09:35):
patients within 30 minutes or sostart to develop a perfusing
sinus rhythm.
So with that then and thesupport of the ECMO machine and
this early intervention, we'realso finding that these patients
are doing a lot better overall.
They're having better neurologicrecovery because they're not,
because they now have the ECMOcircuit that's delivering good
(09:59):
oxygenated blood to their brain,to their kidneys, to their
livers, and they're not goinginto multi system and organ
failure.
They don't have as much, as highof risk of having like hypoxic
neurologic injury and stuff likethat.
So these patients, we're takingpatients that normally probably
would have a pretty poorprognosis even if they did have
return of a perfusing rhythm andwe're taking them and we're
(10:20):
turning them into patients thatnow have the ability to have
meaning neurologic recovery andlimited end organ failure while
their heart recovers and is ableto kind of either undergo
stenting or treatment orwhatever is necessary to sort of
get them through their arrest.
that was
Kanny (10:37):
a great summary of of what, of what the treatment is.
And and I think it leads to thenext question for Suzanne, which
is, Obviously, this is typicallydone at tertiary centers, but
who are the components of yourteam that are required to
provide this kind of advancedtechnique and, and how is that
team activated when an eligiblepatient arrives?
Suzanne (10:58):
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, howthey've defined the team.
But overall, the team makeup isvery actually similar when you
think of the principles thatyou're trying to achieve.
(11:19):
I know some places have thecannulation done in the
emergency room.
Some do it in the cath lab, somechoose to, you know, get them
into an OR.
or the hybrid OR would beanother alternative.
And so that will define whatyour team members are.
At, at UC Health, University ofCincinnati, we, we have chosen a
(11:43):
model where the activationoccurs by our, for out of
hospital arrest.
It, it occurs with our EMS, ouremergency medical services
personnel, specifically theCincinnati Fire Department.
And they activate it, and it, itrings into our emergency room
(12:04):
resuscitation area.
That person then activates it inour in, in house communication
system, and that Actuallyconnects with our in house ECMO
specialist, we haveperfusionists who are at home
our cardiac surgeons and ourcath lab staff and our
(12:27):
interventional cardiologists andthen our critical care folks.
And of course, all the othervery important members of our
team, which is nursing, nursingsupervisor.
That, that alarm, in ouranesthesia department, that
alarm goes out.
We have a process in place thatwhen they hit the emergency
department, there's about fivedifferent important inclusion
(12:47):
criteria that need to beidentified.
All of our EMS folks use theLucas device, which Dr.
Gray had mentioned earlier amechanical CPR device.
If we know the person's acandidate then we would quickly
triage, less than five minutes,triage them to our hybrid suite
(13:09):
or the designated interventionalsuite and the members that align
there after we get through theemergency department where we
have our critical care teammembers, which could be an
anesthesiologist or emergencymedicine doc on our team they
work collaborative with the ERdoc to identify candidacy, and
then we quickly transport withour team members.
(13:31):
CVSU charge nurse and somemembers of the emergency
medicine team up to our hybridsuite We have our anesthesiology
team, which could be made up ofnot only anesthesiologists, but
residents or CRNAs And and thenwe have our ECMO specialist with
our perfusionist driving in.
Just like Dr.
Gray referenced.
(13:51):
We do have our cannulatorscoming in from home and we are
fortunate enough to have ourcardiac surgeons who all live
within a.
Less than 15 minute drive to thehospital and our intervention
list have varying degrees ofproximity to the institution,
but it's all hands on deck.
(14:12):
And whoever gets there, who hasthe most experience then would
start the cannulation.
And the leader of the code orthe event is the critical care
physician who's trying to ensurethat.
All of our standard work thatwe've identified that needs to
be done is being done theconductor, let's say, of, of, of
(14:35):
the, the team of people who areworking together to try to save
this patient and get them onfull support ECMO, so it's a
whole host of people and if oneperson is missing, it's palpable
because everybody fulfills arole and this time sensitive
emergency scenario.
Ellen (14:57):
That's actually a great point.
One question I had for you, andthis might be a little bit
different from one institutionto the next, is once you get
these people on support, they'reon ECMO, what is the role, does
everybody get left heart cathand PCI, who goes for CABG, once
we're on support, what is thenext step?
(15:17):
And is there a specific protocolsince time is of the essence for
these patients?
Kelsey (15:21):
Yeah, so we have a very specific protocol for our
patients and how they kind offlow through their eCPR journey,
if you will.
So we have it very, very laidout from inclusion criteria to
next steps.
So we have three hard inclusioncriteria.
That patients must meet.
(15:43):
They must meet two out of thethree criteria to even be
considered for cannulation.
If you don't meet two out of thethree, we can still make a group
decision to cannulate, but thenthe patient is immediately
bumped out of our E.
C.
P.
R.
Protocol.
So the are hard criteria are aP.
H.
Greater than seven, a lactateless than or equal to 15 and an
(16:03):
end title C.
O.
Two greater than 10.
These are all markers of havinghigh E.
Quality chest compressions andhigh quality A.
C.
L.
S.
Prior to us intervening fromECMO standpoint after the
decision has been made tocannulate, they get cannulated
and where that happens.
I think I agree.
It just it varies frominstitution to institution for
us.
It happens in the E.
R.
(16:25):
We have a cooling protocol, sothe next step is, is once
they're on ECMO, they become,they start we start initiating
our hypothermia protocol andcool them to 35 to 36 degrees
via the ECMO circuit.
We stop the mechanical CPR, andthen the next step is once the
ECMO cannulas are secured, thesepatients are immediately
transferred to the cath lab.
(16:46):
if they have a pathology that'ssuggestive of coronary artery
disease, meaning they had a VTor VF arrest, which is one of
the main criteria for gettingincluded into eCPR, and they had
EKG changes supportive ofischemia at the time that the,
or if they've had EKG changes atany point in time supportive of
(17:07):
ischemia.
If we don't know the cause, theystill go to the cath lab.
So our protocol is veryspecific.
It goes ER.
cath lab.
And in the cath lab, we alsohave a very protocolized
approach.
And this sort of, this cameabout through many meetings with
our interventional cardiologiststhat we partnered very closely
with in starting this program.
(17:27):
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 thatwe reached is that every patient
goes for a diagnostic angiogram.
We do have some patients whereit's very clear that there's
some different pathology.
And in those cases, we don'ttake them to the cath lab, and
(17:47):
we can get into those kind ofoutliers more, but this is in
general our protocol.
And so they go to the cath laband they get a diagnostic
angiogram.
Now, if on that cath there is aisolated proximal lesion in the
LAD isolated left main, isolatedproximal RCA, something that is
(18:07):
a straightforward PCI, then thegeneral agreement is is that
that patient will undergointervention for what is thought
to be the culprit lesion.
There's no extensive stenting.
There's no multi vesselstenting.
If there's no, if it's a complexlesion or multi vessel coronary
disease or something that's alot more complicated, we don't
(18:28):
undertake it at that time.
The patient remains on ECMO andis transferred from the cath
lab.
to the cardiac surgery ICU,where they kind of are, are
managed medically from thatpoint on.
One, if it's a more complex PCIproblem, and it's not something
that's a like an easy,straightforward stent, then what
we do is we wait for thatpatient to show kind of
(18:49):
meaningful neurologic recovery,like reversal of any end organ.
Dysfunction, anything that'sgoing to give them, like,
basically we need to haveevidence of a good prognosis,
and then at that point they'llgo and they'll usually get some
sort of PCI at that point.
Ellen (19:07):
Wonderful.
Dr.
Bennett, is your protocol inyour system set up similarly, or
are there some certaindifferences at UC?
Suzanne (19:17):
You know, it's actually very similar when it comes, when
it comes to whether or not tointervene.
I, you know, just stepping backa little bit, that initial
criteria, which I think Dr.
Gray had alluded to earlier wasthat, you know, to get
cannulated, we looked at.
The patient's they must have awitnessed cardiac arrest with
(19:40):
immediate and by immediate, Imean, less than five minutes
bystander CPR, a shockablerhythm and never being in a
systole.
And then, of course, an age, theage gets a little complicated
because you often don't know theage of the patient, but you want
to make sure that we know thatthe outcomes worsen after the
(20:03):
age of 70.
So That's one that takes alittle bit more finesse and,
and, and decision making afterwe've made the decision that
they meet that criteria then thenext step is very, I mean, it
might even be the same Dr.
Gray for we are in the processof cannulating, we get an
(20:25):
arterial blood gas, if we don'thave access to arterial, then we
get a venous, but either way weget a blood gas that
demonstrates that the lactate isless than 15.
Your end tidal CO2 is greaterthan or equal to 10 millimeters
of mercury.
We also include a PaO2 ofgreater than or equal to 50
millimeters of mercury.
And of course, going back tothat very important rhythm,
(20:46):
which has never had a systole.
And at that point they go onECMO.
And, and what I've found is wecannulate, we get on full flow
ECMO, we can breathe.
At that point, we pause, and nowwe come together to discuss next
steps for this patient.
And if we believe this is acardiac event that has driven
(21:10):
the arrest we do exactly as DrGray outlined with, with
relation to intervening on theculprit lesion.
And, and, and the other thingthat we didn't really talk about
a little bit here is that Youknow, you get your two cannulas
in.
But we also wanna address distallimb ischemia, which we, we have
(21:31):
to include in those discussionsof timing when we ensure that,
that the limb where we'vecannula done, the arterial
cannulation has adequateperfusion.
And the we have chosen to adopta distal li limb a distal
perfusion cannula on all thelimbs that we have in arterial
cannula in.
(21:52):
And how we do it really dependson the patient and their
anatomy.
Having said all that, I thinkjust like she had alluded to,
our decisions are focused aroundwhat's best for the patient and
being malleable to those asopposed to having very, very
strict protocol that may not bepertinent to what the patient
needs.
Kanny (22:12):
I just wanted to talk a little about, like, what
specific outcomes We know fromthe evidence base are improved,
with this therapy.
I know a lot of the studies inthe literature come from single
centers.
There are typically not a lotof, you know, high number of
patients in the studies, becauseobviously it's a really
challenging patient populationto enroll in trials, and of
(22:33):
course randomized trials areeven more difficult.
Kelsey (22:36):
So, yeah, this is a really great question.
One of the most stark kind ofvisual representations of this
that I've ever seen is in thecirculation article that was
published by Dr.
I think it's Yiannopoulos andhis team, and he's done a ton of
work in this.
And he has this is thisincredible graphic that shows it
maps the duration of CPR Overtime and your rate of
(23:01):
neurologically feasible survivaland on this graph, you see this
line at 10 minutes that you have75 percent survival with
traditional A.
C.
L.
S.
And by 30 minutes, you're downto less than 2 percent survival
with traditional A.
C.
L.
S.
And now and then he maps thatconversely with patients who've
had E.
C.
P.
R.
(23:21):
And at 20 minutes, if you'recannulated and put on eCPR and
you meet all these inclusioncriteria that we kind of laid
out, you'll have almost 100percent neurologically favorable
survival.
Okay, now this isn't truesurvival to discharge from the
hospital, right?
There's a lot of hurdles to getover.
This means that at 20 minutes,with eCPR, if you're cannulated
(23:44):
at 20 minutes, you have almostnearing 100 percent
neurologically favorablesurvival.
And then At 40 to 45 minutes,you're still above a 50 percent
chance of neurologicallyfavorable survival.
At one hour, you're still at 25percent chance of neurologically
favorable survival.
And at 90 minutes, you're atabout Like 15 to 20 percent of
(24:09):
neurologically favorablesurvival.
That means people are actuallysurviving at 90 minutes of high
quality CPR and then gettingplaced on to ECMO.
So this is, I think it's areally stark kind of breakdown
of how beneficial eCPR can bewhen introduced appropriately
into the ACLS algorithm.
(24:29):
Now in terms of how thattranslates to hospital discharge
I can share with you some of ourresults that we've had here and
hopefully, Dr.
Bennett, I know your program iskind of new, but I'm sure you're
having similar outcomes because.
Because of it's really theselection criteria for who gets
cannulated that I think helpspush us in this direction But we
(24:53):
really do see that when youcompare it to standard use of VA
ECMO that we have a lot bettersurvival, so Since we've started
our program our overall ECPRsurvival is about very close
like to 50% It's varied a littlebit because our first few years
we were still kind of learningwho to say yes and no to But in
(25:15):
2024 our eCPR survival was 75percent which is very good When
you compare that to regular VAECMO VA ECMO varies I think You
know, kind of nationally, theaverage VA ECMO survival, and
this is like survival todischarge is closer to about
(25:38):
30%, 30 to 45%, depending oninstitutions, some do a little
better.
Some do a little worse.
It's all about kind of who youselect and who you choose to put
on.
But when you compare that toeCPR, you see that these eCPR
patients are really kind of thepatients that are benefiting
significantly from their runs onVA ECMO, and it's helping their
(26:00):
overall survival.
Wow, this is really impressivedata.
Ellen (26:04):
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 ouroutcomes here at University
Hospitals for all the patientswho are in the program?
And also, Dr.
Bennett, do you track them atUC?
And also, last question is, Isthere a nationwide database for
(26:28):
patients who are being treatedwith eCPR?
Kelsey (26:33):
Yeah, so those numbers that I put up were mentioning
were kind of like a summary ofour numbers, like the 75 percent
survival to discharge from 2024,the years prior, we were more in
that 45 and then 50 percentrange.
But Dr.
Bennett, how are you guys doingwith your first few?
Suzanne (26:55):
Yeah, so I It's, it's funny when we look at our
program, we see that the programitself, not eCPR, but ECMO, we
started in 2014, but didn't havea formal eCPR program till 2020.
That time gap in between, westarted submitting our data to
ELSO.
The extracorporeal life supportorganization that many centers
(27:22):
are submitting their data to.
It's a registry day baseddatabase.
And any data we had between 2014and 2020 is a little bit skewed
for a couple of reasons.
One, we didn't really have, hadnot adopted a formal program and
the definition.
Was more delineated after Ithink it was about 2016 through
(27:44):
ELSO to include what ECPR is,which is that you have your, the
patient is undergoing activeCPR.
Or ROSC within 20 minutes.
Any time frame beyond that isnot eCPR.
However, having said thatKelsey, just like you had
mentioned the Outcomes of ECPRare very selection based and and
(28:11):
of course, cannulatingstrategies are extremely
important as well.
And we have similar outcomes asto what you have described.
Our overall just overall allcomers for ECMO survival that
includes VV is.
65 percent but then when youbreak it down by ECMO, it gets a
(28:36):
little bit different dependingon why they were cannulated.
But for eCPR alone, over thecourse of time, we've also been
able to improve our survival todecannulation and, and, and
Discharge to somewhere between50 and 60%.
And I, just like you hadmentioned over the court over
(28:58):
the course of the last couple ofyears, it feels as though the
outcomes are just improving moreand more with the fidelity of
our team and our selectioncriteria, You asked about the
database.
Many of our centers do reportour data to the, as I mentioned,
the also registry.
(29:19):
The benefit of that is you'reable to benchmark yourself
against like centers, whetherthat be based on volume or
centers of excellence or, onacademic versus not academic.
And I found that to be extremelyvaluable and their database is
even getting better and better,that you can actually they can
(29:42):
generate a mortality, ODE.
So the mortality observed versusexpected.
And very important point thatDr.
Gray mentioned is that thesepatients prior to eCPR had
conventional CPR and theoutcomes were dismal.
And with the Invention andapplication of E.
(30:04):
C.
P.
R.
Were able to improve theiroutcomes more than what they
would have had available tothem.
And And as was mentioned before,it's very hard to have a, a
prospective randomized controltrial that's blinded, double
blinded that we could haverobust studies to support
(30:28):
anything that we're doing, whichis, I think, one of the major
challenges in the adoption andacceptance of eCPR as a standard
of care.
Kanny (30:37):
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 outcomesinformation to kind of guide
implementation of this.
We're kind of up against ourtime, 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
(30:59):
here in Ohio I guess my questionis about how we extend this to
other hospital settings wherePCI is offered, but maybe they
don't have all of themultidisciplinary resources Do
you feel like, over time, thisshould be offered at any center
that offers, you know, 24 hourPCI or at least has the
(31:22):
resources to offer ECMO?
And if so, you know, what aresome of the barriers you think
to implementing it more broadly?
Kelsey (31:30):
Yeah, no, that's a really good question.
And we've been toying with thathere at because, you know We
have a lot of regional hospitalsthat reach communities that if
you have a out of hospitalcardiac arrest, say, out like 30
miles from our main campushospital here, It's very
(31:51):
unlikely that paramedics aregoing to get to you, start ACLS,
and get you to a center whereyou can have eCPR performed in a
really truly timely fashion thatmakes it feasible.
And so one of the things we'vebeen looking at doing is
expanding to one of oursatellite hospitals, which is
Illyria.
And I think It's been in theworks to do this, if not already
approved.
(32:12):
Now, we haven't started doing ityet, but this would be our first
real run at doing it in a muchmore community based setting
where the cardiac surgeons arenot close and you would be
relying very heavily on the cathlab.
And other in hospital providersto do the cannulation.
We do have a, like, a PERT teamand that goes out there and
(32:34):
they're most of thosecardiologists are familiar with
ECMO cannulation, but it's goingto be a real undertaking in
terms of training for us becausewe really are going to have to
train staff to run an ECMOmachine.
You know, I think we're lookingat training cath lab staff.
very much.
to run an ECMO machine.
(32:54):
The perfusionists, you know,live quite a ways away from this
hospital, so it's not reallyfeasible to mobilize our whole
team there like it is to do itcentrally at our bigger
hospital.
So, things you have to take intoaccount are, you know, who's
going to run the ECMO machineuntil perfusion can arrive, and
that's usually training we'vetrained our ER nurses here at
(33:14):
our main campus to do it, and soI think looking at these smaller
hospitals, you're looking attraining, yeah.
ER nurses, ER staff cath labstaff, cath lab nurses even
cardiologists, how to kind ofrun the pump, get things set up,
these sort of things, becauseyou aren't going to have that,
that core team that's normallyresponsible for doing ECMO
(33:36):
there.
So I think that's one of thebiggest hurdles, one of the
things that's being done by Dr.
Yiannopoulos is that he has amobile ECMO unit, so I think
something like that may beanother option for, these
smaller communities that arefurther away, meaning, it gets
(33:57):
activated out in the field andthe It's a giant just basically
mobile ECMO truck that drivesand meets either at the hospital
or at the site in the field andthe patients actually put on
ECMO in the, in the mobile ECMOunit.
So I think there's a lot ofcreative things being done and
people are sort of innovating inthis field in terms of how to
(34:20):
get it out to, Smallercommunities or how to make it
more accessible to people wholive further away from these big
tertiary care centers.
Ellen (34:28):
Wow.
This has been a very excitingdiscussion, and I think there's
a whole lot more to come in thefuture.
I really want to thank Drs.
Gray and Drs.
Bennett for sharing theirexpertise on this topic.
We will have some links to thevarious articles, as well as
some charts and some graphics,if people want to see sort of
(34:49):
the setup and the outcomes.
But I think for now, we're goingto have to.
Say thank you and we will seeyou all for future Cardio Ohio
podcasts.
Thank you.
Thank you so much.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
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