WEBVTT 1 00:00:00.080 --> 00:00:01.280 - So if you're looking at the groin at 2 00:00:01.280 --> 00:00:03.359 - this point, hopefully, in just the amount of 3 00:00:03.359 --> 00:00:04.799 - time that I've talked to you, I would 4 00:00:04.799 --> 00:00:06.480 - have done both of these sticks. And I 5 00:00:06.480 --> 00:00:08.980 - have an anagrade stick going into the SFA 6 00:00:09.119 --> 00:00:11.599 - and micropuncture wire hanging out, and I have 7 00:00:11.599 --> 00:00:12.099 - my 8 00:00:12.480 --> 00:00:12.980 - retrograde 9 00:00:13.439 --> 00:00:14.820 - wire sticking out also. 10 00:00:21.234 --> 00:00:24.535 - Hello, CardioNurse cat masters. Welcome to the Proctor's 11 00:00:24.595 --> 00:00:27.574 - Playbook for VA ECMO. This is Naslo Komush, 12 00:00:27.714 --> 00:00:30.695 - and we are back with doctors Daniel Embender, 13 00:00:31.289 --> 00:00:33.229 - Engage, and Marwan Jumian. 14 00:00:33.609 --> 00:00:36.009 - In the last episode, we discussed data to 15 00:00:36.009 --> 00:00:39.070 - delivery for using VA ECMO. In this episode, 16 00:00:39.129 --> 00:00:41.689 - we will open up the practice playbook as 17 00:00:41.689 --> 00:00:43.929 - Ann and Marwan walk us through an actual 18 00:00:43.929 --> 00:00:44.429 - cannulation. 19 00:00:44.855 --> 00:00:47.734 - As a reminder, doctor Engage is trained in 20 00:00:47.734 --> 00:00:49.034 - interventional cardiology 21 00:00:49.335 --> 00:00:51.034 - and critical care cardiology. 22 00:00:51.495 --> 00:00:54.554 - And doctor Marvin Juman is trained in interventional 23 00:00:54.855 --> 00:00:55.355 - cardiology 24 00:00:55.734 --> 00:00:57.115 - and advanced heart failure. 25 00:00:57.420 --> 00:00:59.920 - Our patient is a 36 year old man 26 00:00:59.979 --> 00:01:01.840 - with acute fulminant myocarditis 27 00:01:02.299 --> 00:01:03.039 - with biventricular 28 00:01:03.420 --> 00:01:07.260 - failure, pulmonary edema, and cardiogenic shock. He couldn't 29 00:01:07.260 --> 00:01:09.760 - be in better hands today. Anna and Marwan, 30 00:01:09.819 --> 00:01:11.819 - thank you for joining us in the Cardio 31 00:01:11.819 --> 00:01:14.325 - Nurse CAT Lab. Thank you so much, Nasley, 32 00:01:14.385 --> 00:01:16.865 - for inviting us back, and I'm excited for 33 00:01:16.865 --> 00:01:17.685 - this conversation. 34 00:01:18.305 --> 00:01:20.704 - I'm planning on learning from Marwan how he 35 00:01:20.704 --> 00:01:22.084 - does this so expertly. 36 00:01:22.704 --> 00:01:25.025 - Looking forward to seeing what you do as 37 00:01:25.025 --> 00:01:27.510 - well. Thank you for inviting me. Okay, team. 38 00:01:27.510 --> 00:01:29.770 - Close your eyes, and let's set the stage. 39 00:01:29.990 --> 00:01:31.909 - We're in the Cath Lab Control Room. The 40 00:01:31.909 --> 00:01:34.150 - lights are dimmed. The patient's on his way. 41 00:01:34.150 --> 00:01:36.310 - We are let it up and ready. And 42 00:01:36.310 --> 00:01:37.670 - what do we need to know about the 43 00:01:37.670 --> 00:01:40.230 - patient to get ready and prepare? And as 44 00:01:40.230 --> 00:01:42.795 - a related question, how do we select cannula 45 00:01:42.795 --> 00:01:43.694 - size and configuration? 46 00:01:44.155 --> 00:01:45.594 - What tools do we need to have in 47 00:01:45.594 --> 00:01:47.115 - our toolkit, and how do we think about 48 00:01:47.115 --> 00:01:50.234 - getting them and obtaining them? Alright. Dan, I 49 00:01:50.234 --> 00:01:51.674 - want you to get out of your lead 50 00:01:51.674 --> 00:01:53.435 - for a minute because it's heavy, and, hopefully, 51 00:01:53.435 --> 00:01:54.715 - we have a lot of years ahead of 52 00:01:54.715 --> 00:01:57.189 - us with our backs and our bodies. Because 53 00:01:57.189 --> 00:01:59.350 - I think that how we set ourselves up 54 00:01:59.350 --> 00:02:02.810 - for success probably begins with our procedural planning, 55 00:02:03.109 --> 00:02:05.430 - and one recommendation, I guess, is that we 56 00:02:05.430 --> 00:02:06.790 - don't do this and let if we can 57 00:02:06.790 --> 00:02:09.110 - avoid it. But, you know, cannulation for VA 58 00:02:09.110 --> 00:02:11.034 - ECMO is a team sport, and it requires 59 00:02:11.034 --> 00:02:13.194 - significant free planning and coordination of care to 60 00:02:13.194 --> 00:02:15.194 - take care of this very sick patient. And, 61 00:02:15.194 --> 00:02:16.715 - hopefully, we have a little time to do 62 00:02:16.715 --> 00:02:19.034 - that, maybe only a few minutes. But at 63 00:02:19.034 --> 00:02:20.954 - least we begin by reviewing the patient's history 64 00:02:20.954 --> 00:02:23.280 - and all of the primary data. This informs 65 00:02:23.280 --> 00:02:25.520 - our support strategy and allows us to determine 66 00:02:25.520 --> 00:02:27.680 - what equipment we need, and, actually, we can 67 00:02:27.680 --> 00:02:30.479 - script how we expect our procedure to go. 68 00:02:30.479 --> 00:02:32.080 - So we wanna make sure that we review 69 00:02:32.080 --> 00:02:34.879 - the patient's pertinent history, including prior imaging of 70 00:02:34.879 --> 00:02:37.039 - the groin and leg vessels by angiography or 71 00:02:37.039 --> 00:02:39.215 - prior CTs, if available. And I think that 72 00:02:39.215 --> 00:02:41.134 - reviewing all this primary data with the team 73 00:02:41.134 --> 00:02:43.534 - is imperative. This includes looking at his echo, 74 00:02:43.534 --> 00:02:44.675 - his invasive hemodynamics, 75 00:02:45.134 --> 00:02:45.634 - angiography, 76 00:02:46.094 --> 00:02:49.314 - CT scans, EKG, and labs. The invasive hemodynamics 77 00:02:49.534 --> 00:02:52.094 - allows us to phenotype the patient as left, 78 00:02:52.094 --> 00:02:54.780 - right, or by the shock. Phenotyping, the shock 79 00:02:54.780 --> 00:02:56.960 - allows us to choose the right support configuration. 80 00:02:57.580 --> 00:02:59.580 - ECCO will additionally allow us to assess the 81 00:02:59.580 --> 00:03:00.080 - biventricular 82 00:03:00.379 --> 00:03:03.340 - function and confirm any valvular disease. And in 83 00:03:03.340 --> 00:03:05.099 - many cases, it may also help us refine 84 00:03:05.099 --> 00:03:07.040 - our differential diagnosis for etiology, 85 00:03:07.485 --> 00:03:09.344 - which would then play into our next treatment 86 00:03:09.405 --> 00:03:09.905 - strategies. 87 00:03:10.205 --> 00:03:13.485 - So for example, wall motion suggests CAD or 88 00:03:13.485 --> 00:03:15.485 - severe MR secondary to a flail or mitral 89 00:03:15.485 --> 00:03:17.724 - leaflet may suggest a delayed complication of a 90 00:03:17.724 --> 00:03:20.604 - myocardial infarction. Obviously, we should also be reviewing 91 00:03:20.604 --> 00:03:22.919 - the EKG in the labs. All of this 92 00:03:22.919 --> 00:03:24.780 - data helps ensure we have the correct diagnosis, 93 00:03:25.000 --> 00:03:27.560 - we've delineated our shock phenotype, and allows us 94 00:03:27.560 --> 00:03:30.280 - to choose the cannulation strategy that is most 95 00:03:30.280 --> 00:03:32.120 - appropriate for this patient, and then we pick 96 00:03:32.120 --> 00:03:32.780 - our equipment. 97 00:03:33.319 --> 00:03:35.080 - So this patient is very unlikely to have 98 00:03:35.080 --> 00:03:37.080 - any contraindications to ECMO based on what we 99 00:03:37.080 --> 00:03:39.375 - know, but, ideally, the team would then run 100 00:03:39.375 --> 00:03:41.615 - through your program's list of relative or absolute 101 00:03:41.615 --> 00:03:42.115 - contraindications 102 00:03:42.495 --> 00:03:43.474 - to VA cannulation. 103 00:03:43.854 --> 00:03:45.775 - At my hospital, we actually have an ECMO 104 00:03:45.775 --> 00:03:47.775 - timeout that we now that we're all let 105 00:03:47.775 --> 00:03:50.194 - it up, that we are going to perform 106 00:03:50.335 --> 00:03:52.194 - immediately before we cannulate. 107 00:03:52.550 --> 00:03:53.750 - And as part of this, we list all 108 00:03:53.750 --> 00:03:56.150 - of our contraindications to cannulation and ensure the 109 00:03:56.150 --> 00:03:58.389 - patient is appropriate for the procedure. So as 110 00:03:58.389 --> 00:04:00.150 - for the actual equipment, you will have to 111 00:04:00.150 --> 00:04:02.150 - select the sizes of your venous and arterial 112 00:04:02.150 --> 00:04:02.650 - cannula. 113 00:04:03.030 --> 00:04:05.110 - Flow through the ECMO circuit is determined by 114 00:04:05.110 --> 00:04:07.564 - the size of your venous drainage cannula. I 115 00:04:07.564 --> 00:04:09.664 - usually attempt to place a twenty five French 116 00:04:09.724 --> 00:04:10.224 - multistage 117 00:04:10.525 --> 00:04:12.465 - venous cannula for most patients, 118 00:04:12.764 --> 00:04:14.764 - although it is possible to use a 21 119 00:04:14.764 --> 00:04:17.805 - or 23 French. For femoral VA ECMO, the 120 00:04:17.805 --> 00:04:20.764 - arterial cannula is usually a 16 to 20 121 00:04:20.764 --> 00:04:22.544 - French single stage cannula. 122 00:04:23.039 --> 00:04:25.279 - This is based on the patient in front 123 00:04:25.279 --> 00:04:27.360 - of us and their vessel size. We may 124 00:04:27.360 --> 00:04:29.139 - know this from prior angiography, 125 00:04:29.519 --> 00:04:32.479 - from review of CT scans, or actually just 126 00:04:32.479 --> 00:04:34.959 - looking at the patient and their size, their 127 00:04:34.959 --> 00:04:35.459 - BSA. 128 00:04:35.794 --> 00:04:38.454 - There's definitely a trend toward using smaller arterial 129 00:04:38.514 --> 00:04:41.154 - cannulas when possible in order to minimize bleeding 130 00:04:41.154 --> 00:04:42.454 - and ischemic complications, 131 00:04:42.834 --> 00:04:44.854 - and to potentially facilitate percutaneous 132 00:04:45.394 --> 00:04:45.894 - removal. 133 00:04:46.274 --> 00:04:49.314 - So some programs are routinely using 16 French 134 00:04:49.314 --> 00:04:49.814 - cannulas 135 00:04:50.199 --> 00:04:51.500 - as their upfront strategy. 136 00:04:51.879 --> 00:04:53.960 - We typically are a program that will use 137 00:04:53.960 --> 00:04:55.100 - 20 French cannulas. 138 00:04:55.800 --> 00:04:57.420 - Most of the, cancellations 139 00:04:58.360 --> 00:04:59.660 - for me are 140 00:05:00.120 --> 00:05:03.000 - done outside the cath lab. So they're done 141 00:05:03.000 --> 00:05:05.564 - in the ICU or in the emergency room. 142 00:05:05.644 --> 00:05:07.404 - Rarely, we have the luxury of time to 143 00:05:07.404 --> 00:05:09.264 - get the patient to the cath lab, so 144 00:05:09.644 --> 00:05:12.685 - we get the ECMO cannulation equipment onto our 145 00:05:12.685 --> 00:05:15.165 - cart, and whenever we have to, we just 146 00:05:15.165 --> 00:05:16.845 - move the cart to the patient's room. The 147 00:05:16.845 --> 00:05:19.004 - cart has, in addition to the vascular access 148 00:05:19.004 --> 00:05:22.439 - kit, cannulas, as Anne mentioned. We have dilators. 149 00:05:22.500 --> 00:05:24.180 - We have the guide wire that I use. 150 00:05:24.180 --> 00:05:26.520 - I usually use an AMPLAS super stiff wire. 151 00:05:26.819 --> 00:05:29.139 - I always dilate before I put the cannula 152 00:05:29.139 --> 00:05:30.660 - in place, and that we always have a 153 00:05:30.660 --> 00:05:33.060 - surgical cut down kit just in case there 154 00:05:33.060 --> 00:05:34.680 - are some issues with access. 155 00:05:35.144 --> 00:05:35.884 - And usually, 156 00:05:36.345 --> 00:05:36.904 - it's the, 157 00:05:37.384 --> 00:05:40.605 - CAN leader, which is typically an interventional cardiologist 158 00:05:40.824 --> 00:05:43.805 - or cardiac surgeon. We have the ECMO 159 00:05:44.105 --> 00:05:44.605 - perfusionist, 160 00:05:45.225 --> 00:05:46.044 - an intensive 161 00:05:46.425 --> 00:05:49.544 - care nurse, or a cath lab nurse, and 162 00:05:49.544 --> 00:05:51.759 - we always have access in the cath lab 163 00:05:51.759 --> 00:05:54.020 - or OR just in case something happens. 164 00:05:54.399 --> 00:05:56.720 - But I agree with everything else that Anne 165 00:05:56.720 --> 00:05:59.699 - said regarding cannulation and cannula size as well. 166 00:05:59.839 --> 00:06:02.740 - That's a really helpful framework for getting prepared. 167 00:06:03.125 --> 00:06:05.365 - In the cath lab, things happen fast and 168 00:06:05.365 --> 00:06:08.264 - things can go south anytime in a heartbeat. 169 00:06:08.645 --> 00:06:11.605 - And to be able to react on time 170 00:06:11.605 --> 00:06:13.845 - and with the best approach, it's really important 171 00:06:13.845 --> 00:06:15.699 - to be prepared, not just for the operator, 172 00:06:15.699 --> 00:06:17.379 - but the whole team. So thank you for 173 00:06:17.379 --> 00:06:20.120 - mentioning the team role as well. From understanding 174 00:06:20.259 --> 00:06:22.819 - the patient to choosing the right cannula, you 175 00:06:22.819 --> 00:06:25.379 - covered everything. Marwan, who should be in the 176 00:06:25.379 --> 00:06:27.620 - room and what equipment do we need on 177 00:06:27.620 --> 00:06:28.120 - hand? 178 00:06:28.454 --> 00:06:28.954 - Typically, 179 00:06:29.334 --> 00:06:30.154 - the cannulator 180 00:06:30.615 --> 00:06:33.095 - and the system, whether it's a fellow or 181 00:06:33.095 --> 00:06:35.654 - if the surgeon is cannulating, typically two people 182 00:06:35.654 --> 00:06:37.675 - scrub in to cannulate the patient. 183 00:06:38.055 --> 00:06:39.435 - We always have a perfusionist 184 00:06:39.894 --> 00:06:41.435 - so that they can hand the cannulas 185 00:06:41.819 --> 00:06:43.899 - and the equipment for us and start the 186 00:06:43.899 --> 00:06:46.300 - circuit, and we also have an intensive care 187 00:06:46.300 --> 00:06:49.419 - nurse. With respect to the equipment, again, as 188 00:06:49.419 --> 00:06:51.579 - I said, we have to have vascular access 189 00:06:51.579 --> 00:06:53.519 - kit. I usually start with a micro puncture 190 00:06:53.834 --> 00:06:55.915 - and use a dilator over an NAPLA super 191 00:06:55.915 --> 00:06:58.394 - stiff wire. For the venous cannula, I use 192 00:06:58.394 --> 00:07:01.834 - a 23, 25 inches cannula multistage, and for 193 00:07:01.834 --> 00:07:04.415 - the arterial cannula, I use a 17 French. 194 00:07:04.634 --> 00:07:06.954 - Unless based on the body size and peripheral 195 00:07:06.954 --> 00:07:09.400 - vascular disease, I may alter that. Having an 196 00:07:09.400 --> 00:07:11.480 - ultrasound for guidance is really good, but in 197 00:07:11.480 --> 00:07:13.240 - case of an emergency, we may not have 198 00:07:13.240 --> 00:07:15.639 - the luxury to do so. And then with 199 00:07:15.639 --> 00:07:17.960 - respect to who's in the room, as I 200 00:07:17.960 --> 00:07:20.360 - mentioned, we have, in addition to that, a 201 00:07:20.360 --> 00:07:22.345 - surgeon is always aware of what's happening. The 202 00:07:22.345 --> 00:07:24.345 - ECMO team is always aware of what's happening 203 00:07:24.345 --> 00:07:25.865 - in case we need to talk about what 204 00:07:25.865 --> 00:07:28.104 - the next step is for the patient. Thank 205 00:07:28.104 --> 00:07:30.204 - you both for going over those details. 206 00:07:30.664 --> 00:07:32.824 - So this is not as a sexy debate 207 00:07:32.824 --> 00:07:35.629 - as LV unloading, but Anna Marwan, what is 208 00:07:35.629 --> 00:07:37.230 - your approach or whether or not to use 209 00:07:37.230 --> 00:07:39.870 - a distal perfusion catheter? And also, we did 210 00:07:39.870 --> 00:07:41.870 - allude to this earlier, but what is your 211 00:07:41.870 --> 00:07:44.750 - approach to adding and unloading device upfront, like, 212 00:07:44.750 --> 00:07:46.350 - right now? Anna, why don't you take it 213 00:07:46.350 --> 00:07:49.365 - first? Okay. So a distal perfusion catheter should 214 00:07:49.365 --> 00:07:51.285 - be a standard of care, and I always 215 00:07:51.285 --> 00:07:54.004 - place one. I think pretty straightforward there. As 216 00:07:54.004 --> 00:07:56.004 - for the unloading device, I think we discussed 217 00:07:56.004 --> 00:07:57.524 - this in our last episode, and so if 218 00:07:57.524 --> 00:07:59.040 - you didn't get a chance to hear that, 219 00:07:59.199 --> 00:08:02.000 - I think this is a very in-depth topic. 220 00:08:02.000 --> 00:08:04.160 - We kind of touched on that. I frequently 221 00:08:04.160 --> 00:08:06.160 - place one. However, as I mentioned, I don't 222 00:08:06.160 --> 00:08:07.699 - think that this is always necessary. 223 00:08:08.080 --> 00:08:09.860 - I think that it's based on an assessment 224 00:08:10.080 --> 00:08:12.584 - of the underlying etiology of the patient's shock, 225 00:08:12.745 --> 00:08:15.785 - the expected time frame for potential recovery, and 226 00:08:15.785 --> 00:08:18.044 - then we're looking for things like aortic pulsatility. 227 00:08:18.425 --> 00:08:21.305 - Is there a pulse pressure of normally, most 228 00:08:21.305 --> 00:08:24.024 - people reference 20 millimeters of mercury and the 229 00:08:24.024 --> 00:08:26.365 - presence of aortic valve opening on ECMO. 230 00:08:26.669 --> 00:08:29.470 - If we have some pulsatility and the aortic 231 00:08:29.470 --> 00:08:31.389 - valve is opening, I don't think that it 232 00:08:31.389 --> 00:08:32.690 - is always necessary, 233 00:08:33.070 --> 00:08:35.870 - but I'll say that just probably out of 234 00:08:35.870 --> 00:08:38.269 - convenience and the fact that our experience has 235 00:08:38.269 --> 00:08:39.889 - been that most people 236 00:08:40.235 --> 00:08:41.915 - are not as pulsatile as we would like, 237 00:08:41.915 --> 00:08:44.654 - don't meet that 20 millimeters of mercury initially 238 00:08:44.715 --> 00:08:45.455 - when cannulated, 239 00:08:45.835 --> 00:08:48.154 - that we frequently are going upfront to an 240 00:08:48.154 --> 00:08:49.215 - unloading device. 241 00:08:49.754 --> 00:08:52.315 - I agree with that. An an integrated perfusion 242 00:08:52.315 --> 00:08:55.139 - sheath is placed routinely in all patients. And 243 00:08:55.299 --> 00:08:57.059 - if you're candidate in the cath lab, most 244 00:08:57.059 --> 00:08:59.240 - likely, the patient will get an unloading device 245 00:08:59.299 --> 00:09:00.820 - until we figure out what the next step 246 00:09:00.820 --> 00:09:03.379 - is. Thank you both for sharing your approach 247 00:09:03.379 --> 00:09:06.420 - to distal perfusion and unloading. It's great to 248 00:09:06.420 --> 00:09:08.899 - hear how you think through that upfront. And 249 00:09:08.899 --> 00:09:10.360 - now let's talk about anticoagulation. 250 00:09:11.134 --> 00:09:14.254 - The patient weighs seventy kilograms How much heparin 251 00:09:14.254 --> 00:09:16.335 - do you ask for, and when does it 252 00:09:16.335 --> 00:09:17.154 - get administered? 253 00:09:17.855 --> 00:09:20.095 - Oh, good question. So our protocol is to 254 00:09:20.095 --> 00:09:22.355 - administer seventy units of heparin 255 00:09:22.735 --> 00:09:23.554 - per kg, 256 00:09:24.039 --> 00:09:27.820 - and it's given after vascular access, but before 257 00:09:27.879 --> 00:09:31.820 - dilation. So for this person, seventy times seventy, 258 00:09:32.200 --> 00:09:35.399 - forty, nine hundred, I would ask for five 259 00:09:35.399 --> 00:09:36.620 - thousand of heparin. 260 00:09:37.285 --> 00:09:39.365 - Perfect. Okay. So let's get the show on 261 00:09:39.365 --> 00:09:41.524 - the road. Marlon, can you please walk us 262 00:09:41.524 --> 00:09:44.725 - through the step by step cannulation strategy, beginning 263 00:09:44.725 --> 00:09:46.165 - with access? And I know you did talk 264 00:09:46.165 --> 00:09:46.985 - about acupuncture, 265 00:09:47.365 --> 00:09:48.884 - but just so that we all have it 266 00:09:48.884 --> 00:09:50.340 - together, how do we do this? 267 00:09:50.740 --> 00:09:52.980 - Ideally, you have to be really, really good 268 00:09:52.980 --> 00:09:54.120 - at access because 269 00:09:54.580 --> 00:09:57.379 - most complications that can happen immediately are related 270 00:09:57.379 --> 00:09:59.160 - to access, especially in eCPR 271 00:09:59.540 --> 00:10:01.940 - when there is chaos in the room. So 272 00:10:01.940 --> 00:10:04.899 - using ultrasound guidance, if you can, placing an 273 00:10:04.899 --> 00:10:07.985 - artery on against access using a micropuncture needle, 274 00:10:08.204 --> 00:10:11.164 - getting access with a micropuncture dilator sheet, and 275 00:10:11.164 --> 00:10:14.284 - then after that, I usually use an AMPLUS 276 00:10:14.284 --> 00:10:18.625 - supersede wire, and I dilate carefully. I usually 277 00:10:18.684 --> 00:10:19.184 - upsize, 278 00:10:19.519 --> 00:10:23.120 - so sampling a 25 inch venous cannula, I 279 00:10:23.120 --> 00:10:25.440 - dilate the track with a 27 so that 280 00:10:25.440 --> 00:10:28.080 - it's easy to get the 25 in without 281 00:10:28.080 --> 00:10:31.519 - having any issues. The enemy for cannulation, especially 282 00:10:31.519 --> 00:10:33.440 - at the bedside, as you dilate is if 283 00:10:33.440 --> 00:10:35.174 - you kink the wire, then that's gonna be 284 00:10:35.174 --> 00:10:35.834 - a problem. 285 00:10:36.134 --> 00:10:37.654 - So the key is to make sure that 286 00:10:37.654 --> 00:10:39.654 - when you remove the dilator, I always move 287 00:10:39.654 --> 00:10:41.454 - the wire in and out just briefly, just 288 00:10:41.454 --> 00:10:43.414 - to make sure that everything is smooth, nothing 289 00:10:43.414 --> 00:10:45.995 - is stuck. Once I put the arterial cannula 290 00:10:46.054 --> 00:10:48.855 - and the venous cannula in place, I clamp 291 00:10:48.855 --> 00:10:50.460 - them, the patient's heparinized, 292 00:10:51.000 --> 00:10:52.600 - and then I use a wet to wet 293 00:10:52.600 --> 00:10:53.100 - connection 294 00:10:53.639 --> 00:10:56.600 - and connect the arterial and venous cannulas and 295 00:10:56.600 --> 00:10:58.860 - start the circuit. If I have the luxury 296 00:10:58.919 --> 00:11:01.240 - of time, I'd like to put the anti 297 00:11:01.240 --> 00:11:03.720 - weight sheath before I put the arterial and 298 00:11:03.720 --> 00:11:06.095 - venous cannulas in just so that the real 299 00:11:06.095 --> 00:11:08.014 - state at that area is covered. So I 300 00:11:08.014 --> 00:11:10.835 - use that under ultrasound guidance, sometimes under fluoroscopy, 301 00:11:11.214 --> 00:11:13.695 - where I can access and visualize the wire 302 00:11:13.695 --> 00:11:16.174 - going down the SFA, so I can place 303 00:11:16.174 --> 00:11:18.879 - a six or a seven error sheet there, 304 00:11:18.879 --> 00:11:20.879 - and then I use that to connect it 305 00:11:20.879 --> 00:11:23.919 - to the arterial of the circuit. Okay. The 306 00:11:23.919 --> 00:11:26.500 - patient cannulas are in, and flow is established. 307 00:11:26.959 --> 00:11:30.399 - Something I love about interventional cardiology is learning 308 00:11:30.399 --> 00:11:32.579 - from different operators' unique styles. 309 00:11:33.154 --> 00:11:35.394 - And is there anything you do differently in 310 00:11:35.394 --> 00:11:36.695 - your cannulation strategy? 311 00:11:37.315 --> 00:11:40.274 - So I've done one thing that is slightly 312 00:11:40.274 --> 00:11:42.835 - different and how I've taught fellows to do 313 00:11:42.835 --> 00:11:43.575 - this also 314 00:11:44.195 --> 00:11:46.580 - is that I think that the anagrade reperfusion 315 00:11:47.039 --> 00:11:49.039 - sheath, the stick for that, can actually be 316 00:11:49.039 --> 00:11:49.860 - very complicated. 317 00:11:50.240 --> 00:11:51.519 - I find it to be one of the 318 00:11:51.519 --> 00:11:54.480 - more complicated sticks that we do. It's high 319 00:11:54.480 --> 00:11:56.320 - risk and there's a lot riding on it. 320 00:11:56.320 --> 00:11:58.399 - We're gonna cause ischemia to this leg, and 321 00:11:58.399 --> 00:12:01.705 - then we're gonna systemically anticoagulate them. So, we 322 00:12:01.705 --> 00:12:03.644 - have just a lot of risk for ischemia 323 00:12:03.785 --> 00:12:06.345 - to the leg. So with the exception of 324 00:12:06.345 --> 00:12:06.845 - ECPR, 325 00:12:07.225 --> 00:12:08.985 - I think that is not the situation I'm 326 00:12:08.985 --> 00:12:10.985 - talking about, but I find it much easier 327 00:12:10.985 --> 00:12:13.304 - to do the distal perfusion catheter stick at 328 00:12:13.304 --> 00:12:15.750 - the same time as my retrograde stick. So 329 00:12:15.750 --> 00:12:16.790 - what I mean by this, if I, like, 330 00:12:16.790 --> 00:12:17.990 - walk you through what I do with my 331 00:12:17.990 --> 00:12:20.230 - hands, is that I hold the vascular ultrasound 332 00:12:20.230 --> 00:12:22.389 - probe with my left hand, and I stick 333 00:12:22.389 --> 00:12:24.950 - the common femoral artery in a retrograde fashion 334 00:12:24.950 --> 00:12:26.730 - using my right hand with the micropuncture 335 00:12:27.029 --> 00:12:29.605 - needle. I then wire the micropuncture needle with 336 00:12:29.605 --> 00:12:32.245 - the micropuncture wire, remove the needle, and then 337 00:12:32.245 --> 00:12:34.485 - I just leave the wire there. Not going 338 00:12:34.485 --> 00:12:37.144 - anywhere. It's there. And then I quickly 339 00:12:37.605 --> 00:12:39.524 - swap my hands. So I'm holding the probe 340 00:12:39.524 --> 00:12:42.100 - with my right hand. I scan down just 341 00:12:42.100 --> 00:12:43.779 - a little bit towards the feet until I 342 00:12:43.779 --> 00:12:46.019 - find the SFA and a good target for 343 00:12:46.019 --> 00:12:48.039 - my ana grade sheath. And then I quickly, 344 00:12:48.259 --> 00:12:50.419 - using my left hand, do an ana grade 345 00:12:50.419 --> 00:12:52.519 - stick with this left hand and the micropuncture 346 00:12:52.659 --> 00:12:55.285 - needle. And I again place the micropuncture wire 347 00:12:55.285 --> 00:12:57.924 - through the needle, remove the needle. And so 348 00:12:57.924 --> 00:12:59.205 - if you're looking at the groin at this 349 00:12:59.205 --> 00:13:01.205 - point, hopefully, in just the amount of time 350 00:13:01.205 --> 00:13:02.725 - that I've talked to you, I would have 351 00:13:02.725 --> 00:13:04.485 - done both of these sticks. And I have 352 00:13:04.485 --> 00:13:07.045 - an anagrade stick going into the SFA and 353 00:13:07.045 --> 00:13:09.509 - micropuncture wire hanging out, and I have 354 00:13:10.129 --> 00:13:10.789 - my retrograde 355 00:13:11.169 --> 00:13:14.850 - wire sticking out also. So then I usually 356 00:13:14.929 --> 00:13:16.450 - if I have a reasonable view, I've done 357 00:13:16.450 --> 00:13:18.370 - this in less than thirty seconds. I then 358 00:13:18.370 --> 00:13:20.289 - pick one wire to work on first. I 359 00:13:20.289 --> 00:13:21.589 - place the four French micropuncture 360 00:13:21.889 --> 00:13:24.304 - sheath, remove the micropuncture wire, wire with an 361 00:13:24.304 --> 00:13:26.144 - o three five wire, and place a six 362 00:13:26.144 --> 00:13:28.384 - French pinnacle sheath on each wire. So each 363 00:13:28.384 --> 00:13:29.745 - stick, and I end up with two six 364 00:13:29.745 --> 00:13:32.225 - French pinnacle sheaths. And then hopefully, I've done 365 00:13:32.225 --> 00:13:34.625 - excellent access at that point, and I can 366 00:13:34.625 --> 00:13:37.284 - begin to upset, to dilate, and cannulate. 367 00:13:37.759 --> 00:13:39.039 - And I think that this allows for the 368 00:13:39.039 --> 00:13:40.720 - best view that I can get without a 369 00:13:40.720 --> 00:13:43.519 - cannula in the way to maneuver around, and 370 00:13:43.519 --> 00:13:45.620 - I get the best image that I can. 371 00:13:45.919 --> 00:13:48.179 - So it's much easier to do this before 372 00:13:48.240 --> 00:13:50.879 - you've decreased your flow down the SFA after 373 00:13:50.879 --> 00:13:53.235 - the placement of a big arterial cannula. So 374 00:13:53.235 --> 00:13:54.134 - this is my routine. 375 00:13:54.595 --> 00:13:56.595 - So long as, you know, the patient's actively 376 00:13:56.595 --> 00:13:57.654 - undergoing CPR, 377 00:13:58.115 --> 00:14:00.514 - I do not put the reperfusion sheath in 378 00:14:00.514 --> 00:14:02.115 - at the same time. But I really think 379 00:14:02.115 --> 00:14:03.315 - that if you do this and you do 380 00:14:03.315 --> 00:14:05.475 - it kind of in this way, that normally 381 00:14:05.475 --> 00:14:06.914 - I can have all of that done in 382 00:14:06.914 --> 00:14:08.514 - less than thirty seconds, and I'm willing to 383 00:14:08.514 --> 00:14:10.009 - take that in order to get a good 384 00:14:10.009 --> 00:14:10.509 - stick. 385 00:14:10.970 --> 00:14:13.370 - And that was a super useful, useful tip, 386 00:14:13.370 --> 00:14:15.449 - and I've definitely seen it perform the other 387 00:14:15.449 --> 00:14:17.049 - way where you have your cannula in and 388 00:14:17.049 --> 00:14:19.690 - it becomes just so, so challenging afterwards. I 389 00:14:19.690 --> 00:14:22.009 - am positive that our listeners are going to 390 00:14:22.009 --> 00:14:24.334 - appreciate that tip and trick. So, Anna Marwan, 391 00:14:24.475 --> 00:14:27.774 - what is the vascular closure strategy during decannulation? 392 00:14:28.315 --> 00:14:31.274 - Is it typically performed surgically or percutaneously at 393 00:14:31.274 --> 00:14:33.195 - either of your institutions? Let's start with you, 394 00:14:33.195 --> 00:14:35.195 - Anna. Yeah. So I actually think that we 395 00:14:35.195 --> 00:14:36.334 - are an evolution 396 00:14:36.875 --> 00:14:39.294 - with this. And as we progress and everyone's 397 00:14:39.330 --> 00:14:40.790 - skill sets are improving, 398 00:14:41.170 --> 00:14:42.389 - our first line strategy 399 00:14:42.769 --> 00:14:45.570 - is a surgical cut down, and we've kind 400 00:14:45.570 --> 00:14:48.230 - of oscillated between that being with our cardiothoracic 401 00:14:48.610 --> 00:14:51.649 - surgeons or our vascular surgeons. But just given 402 00:14:51.649 --> 00:14:55.544 - scheduling constraints and resource availability with the cath 403 00:14:55.544 --> 00:14:56.605 - lab and ORs, 404 00:14:57.144 --> 00:14:59.065 - we have gone to a pathway where we 405 00:14:59.065 --> 00:15:00.044 - can do percutaneous 406 00:15:00.585 --> 00:15:01.085 - decannulation. 407 00:15:01.625 --> 00:15:04.764 - And so for patients who are being cannulated 408 00:15:04.825 --> 00:15:06.985 - within our hospital, where it's one of our 409 00:15:06.985 --> 00:15:10.044 - program is one that interventional cardiology will cannulate 410 00:15:10.105 --> 00:15:12.480 - for ECMO in the cath lab if time 411 00:15:12.480 --> 00:15:13.940 - allows. That is our standard. 412 00:15:14.240 --> 00:15:16.100 - And in that situation, if it's an interventional 413 00:15:16.160 --> 00:15:19.759 - cardiologist who did the access, we expect that 414 00:15:19.759 --> 00:15:22.000 - there will be imaging of the access so 415 00:15:22.000 --> 00:15:23.680 - we know what the vessel looks like and 416 00:15:23.680 --> 00:15:25.519 - whether or not we were successful with a 417 00:15:25.519 --> 00:15:28.085 - good stick. And then in that situation, 418 00:15:28.465 --> 00:15:29.605 - so we do angiography, 419 00:15:30.465 --> 00:15:33.285 - and then we will pre close our ECMO 420 00:15:33.345 --> 00:15:34.325 - cannula sites. 421 00:15:34.785 --> 00:15:36.945 - And then if we did it, we know 422 00:15:36.945 --> 00:15:38.945 - the vessel anatomy, we know the stick, and 423 00:15:38.945 --> 00:15:40.879 - we pre closed, then we will percutaneously 424 00:15:41.740 --> 00:15:42.240 - decannulate. 425 00:15:42.700 --> 00:15:44.639 - If we didn't have time to preclose, 426 00:15:45.180 --> 00:15:46.800 - then we can still percutaneously 427 00:15:47.259 --> 00:15:49.600 - do this. We would cross clamp both cannulas 428 00:15:49.899 --> 00:15:51.279 - and then use a 429 00:15:51.660 --> 00:15:53.660 - 16 or 18 gauge needle to stick the 430 00:15:53.660 --> 00:15:55.694 - soft the plastic part of of the cannula, 431 00:15:55.914 --> 00:15:58.235 - wire the so put the large bore needle 432 00:15:58.235 --> 00:15:59.834 - in. You're gonna get shot with a little 433 00:15:59.834 --> 00:16:01.855 - bit of blood even after you've cross clamped. 434 00:16:02.074 --> 00:16:05.355 - Then we would wire with the Amplat super 435 00:16:05.355 --> 00:16:08.495 - stiff wire and come out with the cannula. 436 00:16:09.029 --> 00:16:10.009 - Depending on the situation, 437 00:16:10.470 --> 00:16:11.449 - we would 438 00:16:11.750 --> 00:16:14.169 - potentially use, like, a two eight French technique 439 00:16:14.389 --> 00:16:17.110 - where we put one eight French cannula over 440 00:16:17.110 --> 00:16:20.070 - the wire. We then would put in a 441 00:16:20.070 --> 00:16:23.509 - second wire, remove so two wires through the 442 00:16:23.509 --> 00:16:24.490 - eight French cannula, 443 00:16:24.914 --> 00:16:28.034 - remove the first eight French sheath, and then 444 00:16:28.034 --> 00:16:31.235 - rewire each wire with an eight French cannula 445 00:16:31.235 --> 00:16:34.115 - and perclose both of those. Sometimes depending on 446 00:16:34.115 --> 00:16:36.115 - how good of a pressure holder I have 447 00:16:36.115 --> 00:16:38.500 - from a cath lab tech, we would actually 448 00:16:38.500 --> 00:16:40.500 - just come out with the catheter or the 449 00:16:40.500 --> 00:16:43.539 - cannula over the Amplat super stiff wire and 450 00:16:43.539 --> 00:16:45.240 - then deploy two pre closes. 451 00:16:45.700 --> 00:16:47.940 - If we do that, we always before we 452 00:16:47.940 --> 00:16:50.839 - remove the wire for the second pre close, 453 00:16:51.035 --> 00:16:54.235 - we take a four French micropuncture sheet and 454 00:16:54.235 --> 00:16:55.835 - image just to make sure that it doesn't 455 00:16:55.835 --> 00:16:58.315 - look like we've occluded the blood vessel. And 456 00:16:58.315 --> 00:17:00.014 - I would say that if you're doing percutaneous 457 00:17:00.634 --> 00:17:01.134 - decannulation, 458 00:17:01.835 --> 00:17:03.835 - knowing that what your pulses are in your 459 00:17:03.835 --> 00:17:06.399 - foot on the side you're decannulating before you 460 00:17:06.399 --> 00:17:08.960 - start is really imperative, so you know what 461 00:17:08.960 --> 00:17:12.259 - you're comparing to after you've successfully percutaneously 462 00:17:12.799 --> 00:17:13.299 - decannulated. 463 00:17:13.919 --> 00:17:16.799 - And Marwan? Yeah. So with the evolution of 464 00:17:16.799 --> 00:17:18.179 - temporary support devices, 465 00:17:18.605 --> 00:17:20.684 - a lot of patients are sent to the 466 00:17:20.684 --> 00:17:23.345 - Operating Room for a VEQMOD decannulation, 467 00:17:23.964 --> 00:17:26.125 - and they proceed to get an Impella five 468 00:17:26.125 --> 00:17:28.065 - point five. So the patients in the Operating 469 00:17:28.125 --> 00:17:31.484 - Room, the surgeons will decannulate and then cannulate 470 00:17:31.484 --> 00:17:34.259 - for LV only with an Impella 5.5. So 471 00:17:34.420 --> 00:17:36.820 - we have not done a lot of cath 472 00:17:36.820 --> 00:17:38.119 - lab ECMO decannulation 473 00:17:38.500 --> 00:17:40.900 - unless it's planned, such as for high risk 474 00:17:40.900 --> 00:17:43.460 - PCR as a temporary thing during an AMI, 475 00:17:43.460 --> 00:17:45.859 - then they are pre closed, and then we'll 476 00:17:45.859 --> 00:17:47.940 - do post closure, you know, with per closed 477 00:17:47.940 --> 00:17:50.654 - devices, but that's about it. Yeah. I think 478 00:17:50.654 --> 00:17:52.494 - it's actually a really interesting point. I think 479 00:17:52.494 --> 00:17:55.294 - that this is totally program dependent and that 480 00:17:55.294 --> 00:17:57.934 - it's depending on what your resources are. I 481 00:17:57.934 --> 00:17:59.855 - think you're exactly right, Marwyn, that a lot 482 00:17:59.855 --> 00:18:02.095 - of times, people are going anyways to the 483 00:18:02.095 --> 00:18:04.579 - lab. And truly, when you see what the 484 00:18:04.579 --> 00:18:07.859 - surgeons can Fogarty out of these common femoral 485 00:18:07.859 --> 00:18:10.679 - arteries, there's usually a good amount of thrombus 486 00:18:10.740 --> 00:18:13.940 - there. So we are building our experience with 487 00:18:13.940 --> 00:18:14.440 - percutaneous. 488 00:18:15.140 --> 00:18:17.125 - My first, I shut down the leg. So 489 00:18:17.125 --> 00:18:18.325 - at that point, you're like, well, do you 490 00:18:18.325 --> 00:18:19.765 - call it or not? Do we ever do 491 00:18:19.765 --> 00:18:22.164 - this again? But we sort of advanced in 492 00:18:22.164 --> 00:18:24.085 - kind of being more selective. If we do 493 00:18:24.085 --> 00:18:24.664 - a percutaneous 494 00:18:24.964 --> 00:18:25.464 - decannulation, 495 00:18:26.005 --> 00:18:28.724 - we always have a surgeon who is aware 496 00:18:28.724 --> 00:18:29.704 - and available. 497 00:18:30.049 --> 00:18:31.809 - And then, obviously, if you have the skill 498 00:18:31.809 --> 00:18:34.069 - set as an interventionalist to get at collateral 499 00:18:34.130 --> 00:18:36.130 - access and come up and over and sometimes 500 00:18:36.130 --> 00:18:38.289 - bail your own yourself out, that is an 501 00:18:38.289 --> 00:18:40.289 - additional a good skill set to have. I 502 00:18:40.289 --> 00:18:42.929 - will say that our surgeons are frequently some 503 00:18:42.929 --> 00:18:45.934 - of them perclose on their own, but frequently, 504 00:18:45.994 --> 00:18:48.634 - one of the interventional cardiologists will pop in 505 00:18:48.634 --> 00:18:50.474 - even if they're going for a five five 506 00:18:50.474 --> 00:18:53.694 - or they're being surgically decannulated just to perclose 507 00:18:53.914 --> 00:18:57.034 - the anagrade reperfusion sheath, just to make that 508 00:18:57.034 --> 00:18:58.554 - one less thing that they have to deal 509 00:18:58.554 --> 00:19:00.575 - with and potentially a smaller incision. 510 00:19:01.299 --> 00:19:03.880 - Thank you both for sharing your unique experiences 511 00:19:03.940 --> 00:19:06.660 - and your approaches. It's always really helpful to 512 00:19:06.660 --> 00:19:09.380 - hear from different operators and how things go 513 00:19:09.380 --> 00:19:10.519 - in different institutions. 514 00:19:11.059 --> 00:19:13.299 - And and Marwan, thank you for this amazing 515 00:19:13.299 --> 00:19:16.275 - collaboration on such a fun and insightful episode. 516 00:19:16.575 --> 00:19:18.974 - I truly enjoyed diving into the nuances of 517 00:19:18.974 --> 00:19:20.115 - VA ECMA cannulation 518 00:19:20.414 --> 00:19:22.115 - and hearing your unique strategies, 519 00:19:22.414 --> 00:19:24.595 - from mechanical unloading to anticoagulation, 520 00:19:25.134 --> 00:19:28.494 - vascular closure, and everything in between. Cardio Nurse 521 00:19:28.494 --> 00:19:28.994 - Catmasters, 522 00:19:29.535 --> 00:19:30.914 - thanks for joining us. 523 00:19:31.250 --> 00:19:33.730 - Stay tuned for our next episode of Crisis 524 00:19:33.730 --> 00:19:36.150 - Control, where we tackle complications 525 00:19:36.450 --> 00:19:39.330 - head on, because the real mastery begins when 526 00:19:39.330 --> 00:19:41.269 - things get tough. See you there.