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

Case #1 Han anging on on t to L o Life By y a Th a Thin Th Thread 14 years old boy transferred to DCC 27 th December 2017 in decompensated NYHA Class IV heart failure in cardiogenic Shock(EF= 10-15%). ECHO: Severe Bi-Ventricular dysfunction EF 10-15%-LVEDD 6.5 mm Severe Mitral regurgitation SPAP 50 mmHg TAPSE 12

27 th December 2017 : VA ECLS 28 th December 2017: IABP 29 th December 2017: Urgent Heart-Ware LVAD Minimally Invasive Technique(1 st in Gulf and ME in an Adolescent) 2 nd January 2018: VA ECLS Decannulated Protek Duo Placed. 3 rd 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 oblems 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• 4th January 2018: 7 am Sedation withdrawn .Fully awake responding.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. The first Syncardia TAH placed in the Middle East & Gulf Arrhythmogenic Right Ventricular Cardiomyopathy

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)

Cardiac Transplantation 7 th March 2018 I did 4 laps Discharged from Hospital 28 th March 2018 I year later back to Kuwait

Case # e #2: Wrong . When en the e Ri Righ ght i is W 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 Protek Duo Cannula in PA 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.

• 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 • Sepsis • Cardiac arrest • Left Groin Wound Infection • Severe Pulmonary Hypertension • Cardiac Tamponade • Massive Pulmonary Embolism • Left and Right Lung Collapse • Renal failure • Massive Blood Transfusions • DIC • Pneumothorax • Hemolysis • Left Femoral artery massive Bleeding • Generalized Muscle Weakness • Left femoral artery Ligation with • Massive Pulmonary Hemorrhage Extra-Anatomic Fem-Fem Gortex • Ventilator Dependency Bypass • ARDS

List of Procedures • V-A ECLS Fem-Fem • Multiple Bronchoscopies • Circulatory Arrest • Left pneumothorax with Chest Tube insertion • Open Pulmonary Thromboembolectomy/Endarterectomy • Multiple Re-intubations and Tracheostomy • V-A ECLS Decannulation • Multiple re-sternotomies • Left Femoral Artery Dacron Patch • Multiple Explorations L Infected Groin • V-V Protek-Duo R Heart Support • Left Femoral Artery Ligation • RVAD • R Femoral to L femoral extra-anatomic Gortex bypass • V-V ECLS • Multiple Bronchial artery embolizations 72 days in SICU and 24 procedures performed

AT Last Some Good News UK London RB&HF Hospital • 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 • Extensive Cardio-Pulmonary Rehabilitation

Durable MCS Implantation In Crash and Burn Patients Al Dabbous Cardiac Center Jan 2015-Jan 2020 1 Month Mortality 35 Durable MCS were placed in 31 Pts 30% LVAD Redo LVAD RVAD BIVAD BIVAD HMIII Syncardia 70% (Delayed RVAD) (HM6) TAH 26(14) 1(1) 2(2) 2(1) 1(1) 3(3) LV d 52% of patients Intermacs III (8Pts) 1 Month Survival IABP 30% Impella CP 22% 1 Year Survival 26% 31% 69% 74% 26% ≥2 years survival(6 pts) 1pt 5 yrs,2pt 4 yrs.(1Tx),1pt 3yrs.(Tx) 1 Year Mortality Intermacs I (23 Pts) 2pts 2yrs.(1explanted)

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 30Day Mortality 38% (30%) 30Day Survival 62%(70%) I Year Mortality 57% (69%) I Year Survival 43% (31%) 2 Year Mortality 63% (74%) 2 Year Survival 37% (26%)

1 Year LVAD survival after ECLS Calculator App 82% 35% 2% 35

Positive and Negative factors for the INTERMACS I results at Al Dabbous Cardiac Center Positive Factors Negative factors • The only d-MCS center in Kuwait • Kuwait is a small country • Very active t-MCS service • Late Referral of patients for AHF • Advanced heart failure team • Lack of awareness • Partnership with a world leading MCS • MDRO INFECTIONS Center Prof. Jan Schmitto Actinobacter Baumannii Hannover Medical University (MHH) Pseudomonas aeruginosa Klebsiella pneumoniae

Total No. ECLS Cases Al-Dabbous Cardiac Center Jan 2015 – Jan 2020 120 120 113 Total No. Of ECLS Cases = 271 Cases Total No. Of V-A ECLS Cases = 116 Cases 100 100 45 80 80 60 60 60 55 22 22 40 40 68 23 20 20 20 38 33 19 8 5 0 0 1 2015 2016 2017 2018 2019 2015 2016 2017 2018 2019