THE CR CRASH ASHING AN AND BUR URNING NG: Ho How F Far Do - - PowerPoint PPT Presentation

THE CR CRASH ASHING AN AND BUR URNING NG:

Ho How F Far Do Do Y You GO GO?

Professor Riyad Tarazi M.D ,F.A.C.S.

Chief of the Cardiothoracic Surgery Department Head of Mechanical Circulatory Support and Transplantation Salman Al-Dabbous Cardiac Center Al-Adan Hospital – Ministry of Health Kuwait

14 years old boy transferred to DCC 27th December 2017 in decompensated NYHA Class IV heart failure in cardiogenic Shock(EF= 10-15%).

Case #1

Han anging on

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to L

• Life By

y a Th a Thin Th Thread

ECHO: Severe Bi-Ventricular dysfunction EF 10-15%-LVEDD 6.5 mm Severe Mitral regurgitation SPAP 50 mmHg TAPSE 12

27th December 2017:

VA ECLS

28th December 2017:

IABP

29th December 2017:

Urgent Heart-Ware LVAD

Minimally Invasive Technique(1st in Gulf and ME in an Adolescent)

2nd January 2018:

VA ECLS Decannulated Protek Duo Placed.

3rd January 2018: 8 am Persistent VT. Multiple shocks. Hypotension 11 am VA ECLS re-inserted. Sinus rhythm. Low LVAD flow distended RV 7 pm Non-shockable Ventricular fibrillation

?

10 pm Patient was taken to the operating room .Explored. The finding of severely dilated ‘baggy” fibrillating right Ventricle .Suction effect of LV. A.Two Stage Venous Cannula placed in Right atrium. This was “Y” to the right femoral venous cannula of VA ECLS B.10 mm Hemashield Graft sutured to the main PA This was “Y” to the ECLS arterial axillary outflow. Fine tuning of flow control was done by clamping the plastic tubes of ECLS circuit. Now for the first time LVAD flow 2.1 L on ECLS 2.5L Hemodynamically acceptable, fibrillating heart ,anuric on dialysis.

Maj ajor P Probl

• blems Ahe

Ahead

• 1. Brain Status ??????
• 2. The only therapy would be Syncardia TAH.Not available in KU.
• 3. Emergency transplantation .Cardiac Tx never done in KU at that
• time. Scarce donors and the patient would need Heart +/-Kidney Tx.
• 4. If TAH could be placed what center in the world will accept the patient

for later transplantation.

• 5. TAH batteries need 8 hrs. to charge and can not be

sent charged on the plane from Germany.

• 4th January 2018: 7 am Sedation withdrawn .Fully awake responding.
• Due to The Minister of Health immense support prompt purchase of two

50 cc Syncardia TAH was done. The devices were shipped from Germany the next day with uncharged batteries

• 8 hrs. to charge the batteries and proctor Dr. Latif Arusoglu to arrive
• After 55 hrs. of persistent ventricular fibrillation and at 2 am 6th January 2018

Syncardia TAH(50 cc) was inserted, and all ECLS circuits were removed. Chest left open.

• 2 days later the sternum was closed.

Arrhythmogenic Right Ventricular Cardiomyopathy The first Syncardia TAH placed in the Middle East & Gulf

Going Trans-Atlantic

• He was turned down for heart/kidney transplant by

two leading centers in the USA, and one in India. He was accepted by University of Chicago Dr Valluvan Jeevanandem for combined heart and kidney Tx.

• 18 th January 2018 after 22 days of stabilization in

SICU the patient was transferred by air ambulance across Atlantic .This was the longest ever for a Syncardia patient and the world first attempt.

( 36hrs. journey with 4 stops to charge the device batteries)

I did 4 laps

Cardiac Transplantation 7 th March 2018 Discharged from Hospital 28 th March 2018

I year later back to Kuwait

Case # e #2: When en the e Ri Righ ght i is W Wrong.

• 16 yrs. Old, morbidly obese male(155 Kg) with Anti-Phospholipid Syndrome

presented to the ER with severe worsening of SOB for the past 1 week.

• The patient was transferred to SICU.Witnessed cardiac arrest resuscitated.
• There was progressive deterioration in hemodynamics with hypotension and
• hypoxemia. VA Fem-Fem ECLS (#8 mm LCFA Dacron Graft)
• ECHO showed poorly contractile dilated Right ventricle with severe TR and

elevated systemic PAP.

• Duplex Evaluations of upper and lower venous systems did not delineate any

thrombus.

• Massive bilateral Pulmonary Embolism
• Severe Pulmonary Hypertension
• Acute Severe RV dysfunction

Treatment 1

• IV thrombolytic therapy was followed by intra-pulmonary lytic therapy thru the Swan

Ganz with no improvement because when the ECLS was weaned the RV would distend ,PA pressure rise, and systemic pressure drop.

• Pulmonary angiogram thru the Swan showed massive pulmonary embolism with

bilateral distal occlusions of segmental arteries.

• The patient was taken to the operating room for pulmonary Thrombo-embolectomy.
• CPB initiated. Main pulmonary artery opened and to my surprise there were no

massive clots as depicted by CT angiogram. Now I knew that we were

In Deep Trouble!!

Treatment 2

• Under circulatory arrest 10 Min for the RPA and 12 Min for the LPA

pulmonary thrombo-embolectomy with limited endarterectomy was done

• The patient weaned of CPB on V-A ECLS
• Once his lungs improved, V-A ECLS was
• decannulated. The femoral artery graft was

was removed and artery patched with a Dacron patch. The patient was switched to a

Protek Duo cannula for RV support.

• Flow increased to 5 liters with no lung

flooding.

• On 29 th of May 2018 Heart-Ware RVAD

implanted

• Did well Extubated.

Protek Duo Cannula in PA

• Developed pulmonary hemorrhage post

RVAD insertion. He was intubated

• Underwent multiple bronchoscopies with

clot removal, bronchial blockers and 6 bronchial artery embolizations .

• Tracheostomy was done
• Veno-Venous ECLS inserted for O2 support
• He started to improve slowly and V-V ECLS

decannulated. Unexpected Disaster:

The patient had developed Klebsiella Left groin infection and had nearly exsanguinating hemorrhage from dehiscence of the Dacron patch to LCFA.This was managed by emergency ligation of LCFA and extra-anatomic R Fem- L SFA bypass done by vascular surgeons.

List of Complications Resolved

• Cardiogenic shock
• Cardiac arrest
• Severe Pulmonary Hypertension
• Massive Pulmonary Embolism
• Renal failure
• DIC
• Hemolysis
• Generalized Muscle Weakness
• Massive Pulmonary Hemorrhage
• Ventilator Dependency
• ARDS
• Sepsis
• Left Groin Wound Infection
• Cardiac Tamponade
• Left and Right Lung Collapse
• Massive Blood Transfusions
• Pneumothorax
• Left Femoral artery massive

Bleeding

• Left femoral artery Ligation with

Extra-Anatomic Fem-Fem Gortex Bypass

List of Procedures

• V-A ECLS Fem-Fem
• Circulatory Arrest
• Open Pulmonary

Thromboembolectomy/Endarterectomy

• V-A ECLS Decannulation
• Left Femoral Artery Dacron Patch
• V-V Protek-Duo R Heart Support
• RVAD
• V-V ECLS
• Multiple Bronchial artery embolizations
• Multiple Bronchoscopies
• Left pneumothorax with Chest Tube

insertion

• Multiple Re-intubations and Tracheostomy
• Multiple re-sternotomies
• Multiple Explorations L Infected Groin
• Left Femoral Artery Ligation
• R Femoral to L femoral extra-anatomic

Gortex bypass

72 days in SICU and 24 procedures performed

UK London RB&HF Hospital Extensive Cardio-Pulmonary Rehabilitation

AT Last Some Good News

• 5 th June ,2019 RVAD explanted with

a Titanium Plug placed in situ.

• Last seen January 20,2020 he was

doing well BP 135/80 mmHg On Warfarin 7 mg- INR 2.8

• Weight 25 August 2019=86.5 Kg
• Weight 20 January 2020=98.4 Kg
• ECHO: Normal LV systolic and diastolic

function EF 60%.Mild right sided dilatation with impaired RV systolic

• function. TAPSE 14 mm.Mild TR with

SPAP 45-50 mmHg.

• Planning to start patient on Reosiguat for CTEPH

Durable MCS Implantation In Crash and Burn Patients Al Dabbous Cardiac Center Jan 2015-Jan 2020

35 Durable MCS were placed in 31 Pts

LVAD Redo LVAD RVAD BIVAD (HM6) BIVAD HMIII

(Delayed RVAD)

Syncardia TAH

26(14) 1(1) 2(2) 2(1) 1(1) 3(3)

74% 26% Intermacs I (23 Pts) Intermacs III (8Pts) 70% 30%

1 Month Mortality 1 Month Survival

69% 31%

1 Year Mortality 1 Year Survival 26% ≥2 years survival(6 pts) 1pt 5 yrs,2pt 4 yrs.(1Tx),1pt 3yrs.(Tx) 2pts 2yrs.(1explanted) LV d 52% of patients IABP 30% Impella CP 22%

30Day Survival 62%(70%) I Year Survival 43% (31%) 2 Year Survival 37% (26%) 30Day Mortality 38% (30%) I Year Mortality 57% (69%) 2 Year Mortality 63% (74%) Prediction of 1 year Mortality 1.Elevated Bilirubin 2.Elevated C-Reactive Protein 3.Duration of ECLS>7 days 4.Increased BMI>30Kg/m2 5.Female Gender

1 Year LVAD survival after ECLS Calculator App

35

35% 82% 2%

Positive and Negative factors for the INTERMACS I results at Al Dabbous Cardiac Center

Positive Factors

• The only d-MCS center in Kuwait
• Very active t-MCS service
• Advanced heart failure team
• Partnership with a world leading MCS

Center Prof. Jan Schmitto Hannover Medical University (MHH)

Negative factors

• Kuwait is a small country
• Late Referral of patients for AHF
• Lack of awareness
• MDRO INFECTIONS

Actinobacter Baumannii Pseudomonas aeruginosa Klebsiella pneumoniae

Total No. ECLS Cases Al-Dabbous Cardiac Center

Jan 2015 – Jan 2020

23 20 60 55 113

20 40 60 80 100 120 2015 2016 2017 2018 2019

Total No. Of ECLS Cases = 271 Cases

5 1 38 33 68 8 19 22 22 45

20 40 60 80 100 120 2015 2016 2017 2018 2019

Total No. Of V-A ECLS Cases = 116 Cases

Positive and Negative factors for the INTERMACS I results at Al Dabbous Cardiac Center

Positive Factors

• The only d-MCS center in Kuwait
• Very active t-MCS service
• Advanced heart failure team
• Partnership with a world leading MCS

Center Prof.Jan Schmitto Hannover Medical University (MHH)

Negative factors

• Kuwait is a small country
• Late referral of patients for AHF Rx
• Lack of awareness
• MDRO INFECTIONS

Actinobacter Baumannii Pseudomonas aeruginosa Klebsiella pneumoniae

THE CRAS ASHING AND NG AND BURNI NING: NG: How Far D Do

• You
• u G

GO?

NEVER EVER GIVE UP !!!!

Courtesy of Dr. M Morshuis Bad Oeynhausen