Preview Mode Links will not work in preview mode

Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series; a quality, portable and on-demand continuing medical education, that features a variety of exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosts of the program are Fred DeMeuse, PA-C, Jason Hicks, PA-C, and Leah Radde, RN. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Feb 12, 2021

In this podcast Dr. Demetri Yannopoulos, a interventional cardiologist with M Health Fairview and Interventional Cardiology Researcher Director with the University of Minnesota-Twin Cities, discusses ECPR (ECMO Cardiopulmonary Resuscitation), the recent Arrest Trial and the Mobile ECMO program.

Enjoy the podcast!

Objectives:  
  Upon completion of this podcast, participants should be able to:

  • Define the importance of time and quality of CPR on outcomes from out-of-hospital cardiac arrest (OHCA).
  • Explain the role of ECPR and ECMO teams in the management of out-of-hospital cardiac arrest (OHCA) refractory cardiac arrest.
  • Review the current state of the art management of cardiac arrest and the reorganization of EMS/hospital response to out-of-hospital cardiac arrest (OHCA).

CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for Continuing Education (CE) and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview and Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on this presentation. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Demetri Yannopoulos, MD has received honoraria from Helmsley Charitable Trust and the National Institute of Health (NIH) within the past 24 months, as a grant for research studies. Upon an independent review of his presentation, confirms he is following ACCME guidelines, and there is no commercial tie to the named agencies and no impact on his podcast presentation.

Ridgeview's Continuing Education Committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

SHOW NOTES:

Chapter 1: 
CPR was introduced in the 1960s. At the time, research at John Hopkins was being conducted on pigs in ventricular fibrillation and ventricular tachycardia who required defibrillation.  It was noted that when pushing defibrillation paddles against the chest wall, the arterial pressure of the subjects increased. It was concluded that with compression, pulsatile flow was generated. This was essentially the first iteration of closed chest CPR. Over the next 50 years or so, clinicians have been looking for better ways to improve survival outcomes. Key factors include early identification, early CPR, along with obtaining resources and assistance to improve ventilation, perfusion, and defibrillation. Poor predictors of survival for cardiac arrest include CPR for greater than 30 minutes and individuals with coronary artery blockage. With the integration of ECMO, it was found that by bypassing the heart and lungs and essentially taking on their functions, outcomes improved.

Dr. Yannopoulos reiterates that CPR for greater than 30 minutes results in poor outcomes, thereby creating a goal to both normalize pressures during this time while also fixing the offending cause, such as a coronary artery occlusion.  Around 2015, in the Minnesota metro area, visionary EMS directors implemented an alternative option: If a patient fails three shocks, with ongoing CPR, the patient was transferred to a tertiary care facility with ECMO cannulation capabilities. Once on ECMO, these patients were transferred to the University of MN where they underwent PCI to evaluate for reversible causes such as occluded coronary vessels, PE, etc. Outcomes of this therapy showed 30-40% patient survival, which is a game changing result, thus the need for a randomized control trial, the ARREST Trial.

Chapter 2: 
The ARREST Trial studied a group of patients with out-of-hospital cardiac arrest (OHCA) in ventricular fibrillation, refractory to defibrillation and initial ACLS treatment. This was a randomized control trial where one group was randomized to an ECMO intervention arm, versus a standard ACLS therapy arm. It was a phase 2, single center, open-label, adaptive, safety and efficacy randomized clinical trial.  Specific subject criteria included adults aged 18-75 with OHCA, refractory ventricular fibrillation, with no return of spontaneous circulation (ROSC) after three shocks, with an automated cardiopulmonary resuscitation device or LUCAS device and estimated transfer time shorter than 30 minutes. The primary outcome of the trial was survival to hospital discharge. Secondary outcomes included safety, survival and functional assessment at hospital discharge, at 3 months and 6 months after discharge. Results of the ACLS arm showed a 7% survivability, and zero at both three and six months, while the ECMO arm fared better with a 43% survivability.

After enrolling 30 patients, the study was terminated at the first pre-planned interim analysis by the National Heart, Lung and Blood Institute after a unanimous recommendation from the Data Safety Monitoring Board, because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group compared to the standard ACLS group. No unanticipated serious adverse events were observed. Conclusion: early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation, significantly improved survival to hospital discharge compared with standard ACLS treatment.

Chapter 3: 
The Minnesota Mobile Resuscitation Consortium or MMRC, which was the first program to serve an entire metropolitan area in order to rapidly deliver extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation to patients with refractory ventricular fibrillation/ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA).

This was an observational cohort study that analyzed consecutive patients prospectively enrolled in the MMRC's ECMO-facilitated resuscitation program. Entry criteria were identical to the ARREST Trial, adults 18-75 with an out-of-hospital cardiac arrest in VF or CT with no return of spontaneous circulation post 3 shocks, use of a LUCAS or automated cardiopulmonary resuscitation device, and an estimated transfer time of less 30 minutes. The primary endpoint was functionally favorable survival to hospital discharge with Cerebral Performance Category (CPC) 1 or 2. CPC 1 results in good cerebral performance: conscious, alert, able to work, that might have some mild neuro or psych deficits. CPC 2 results in moderate cerebral disability; conscious, sufficient cerebral function for independent activities of daily living (ADLS). Secondary endpoints included 3-month functionally favorable survival.

Between the period of December 1, 2019 and April 1, 2020, 63 consecutive patients were transported, and of these 58 were treated by the mobile ECMO service. Post EMCO treatment 25 of the 58 or 43% were both discharged from the hospital and alive at 3 months with CPC 1 or 2.

This first, community-wide ECMO-facilitated resuscitation program in the US demonstrated 100% successful cannulation, 43% functionally favorable survival rates at hospital discharge and 3 months.

Chapter 4: 
As the research continues, reaching 25-30% positive outcomes would be adequate to start a viable program. Dr. Yannopoulos speculates that with overall system improvement and refined protocols, that number can be as high as 70-80%, which is an incredible number. The future of ECPR will require a combined effort of the healthcare systems, policy makers, administrators, and communities. With a successful program in the urban and suburban areas, future research can hopefully expand access to more rural populations. Dr. Yannopoulos emphasizes that this is not a hospitalized based program, it relies on the EMS system, and those providers, especially medics, are key to the success of the program.

At the time of this interview, the mobile ECMO program was on hold due to COVID, but currently the mobile ECMO program has a pending restart date of March 1st.

Thanks for listening.