I'll go fast, sometimes I talk too much. Please raise your hand so I can slow down a little bit. I did this presentation, I did the presentation mostly by myself, but I have two amazing people that helped me with the chapter. One is my super genius resident, Randy Bock, and then the other colleague of mine is Dr. Irfan Bodani, who actually established an ECMO program during COVID in his institution, so lots of expertise on his side. I have no financial disclosures. As I said, a lot of slides. I wish I can say that all of us are going to be experts by the end of this presentation on ECMO, but we will not be, because each of my slides could be a presentation by itself. Like I said, if I go too fast, somebody raise your hand I'll slow down a little bit. A quick outline, ideally we want to go over a few of the devices that we're going to be discussing and some special circumstances that are applicable to ECMO in my opinion. The future direction is the key of the discussion, and we'll spend some time on that. Did I change that, or it's moving by itself? First, we want to define what cardiogenic shock is, and I want to tell you and disappoint you that there's no clear definition of cardiogenic shock unfortunately today, but basically it is a low flow state. It's described as a vicious cycle, and we cannot get out of it just like similar to the trauma where you have the triad here. We have what's the first thing? We have an ischemic injury, then we go into a low flow state. Then the compensatory mechanism of your body wants to increase the SVR in an attempt to improve circulation, but then it worsens the work of the heart, so we go into this cycle. And ideally we want to be able to intervene as early as possible so we can prevent the start of the cycle or the spiral. In 2019, the Society of Cardiovascular Angiography and Interventions actually proposed this schema of classification of cardiogenic shock, and it was adopted very widely by multiple societies. One of them was ours. I like that they used the color scheme, and also they stratified patients in different categories because I firmly believe that what's the future of medicine is basically if we can stratify risk and being able to prognosticate, we'll be able to provide hopefully cure for everything that's disease-wise today. Five categories, I'm not going to read what's on the slide, and everything is in the book for you to look up afterwards, but I feel like if we can intervene not just with medical management but with the mechanical devices at category B or C, ideally we want to alter outcomes and probably improve survival because the key is improve survival. Etiology of cardiogenic shock, as you can see, a good chunk of it, more than 80% is actually secondary to ischemic events. There is also known ischemic events-related cardiogenic issues. The rest of the cardiomyopathies are there, heart failure, even though irrelevant of the original etiology of the heart failure also is a small chunk. Mortality used to be as high as 50% and that is in the late 60s, 70s prior to the introduction of mechanical support. And as you can see, we've made some improvements but not significant. It's still too high. More than a third of the patients that suffer cardiogenic shock irrelevant of our best attempts are not going to do well. What do we, how do we manage it today? In the society, the HAA and ACC are working on that on a daily basis. They have frequent guidelines, not just here in the US but also the European society. And this is the best that I could summarize in one slide. How do we approach cardiogenic shock today? So emphasis on early diagnosis. Support. So as soon as you define that this is a patient in cardiogenic shock, you want to provide immediate support. Medical and interventional management. And ultimately, we have to identify the underlying cause and correct it. And as you can see, I've listed some numbers that we have the intraaortic balloon pump available since the 60s. And also ECMO since the 70s. And nowadays that we have more devices, obviously we're using more ECMO and durable devices compared to the intraaortic balloon pump. I'm going to go as fast or as slow as I can through the various of the devices. The first one is the intraaortic balloon pump. For the people that are not familiar with that, it's a percutaneously placed device. Ideally it has on the distal end a balloon. The balloon has to be placed just distal to the subclavian artery. It's very important that it's distal to it because it can occlude perfusion. And what it does is it deflates during, I'm sorry, it deflates during systole and it inflates during diastole. So two, serves two purposes. One is as it deflates during systole, it supposedly decreases the afterlife to the left heart. So precipitates forward flow and better perfusion. And the more important part, in my opinion, obviously, is the inflation of balloon during diastole is basically when it increases the coronary perfusion and contributes to augmented match supply oxygen and demand of the heart. Indications, as you can guess, I have a slide for each of my devices that has indications and contraindications. All of the indications are cardiogenic shock. And there are certain specific categories in each of the devices that I'm going to address. That is subspecific to the generalization of cardiogenic shock. And intraaortic balloon pump has a lot of studies. It's been present and available for us for close to 50 years, as you can guess. And people have experimented using it in different situations. So the data is there. Contraindications, there is the absolute contraindication, obviously, if you have aortic regurgitation because every time you inflate this balloon and deflate this balloon, whatever the regurgitation fraction is, you are augmenting it as well. Relative, I am not going to read off my slide. All of you have access to that in the book chapter. But you can imagine that most of it is basically access site related. And also, any generalized issues with hemostasis. Complications, a lot of them are, again, access site related. And some of them are very devastating. I will try to concentrate on specific complications for the devices that we're going to be discussing. And the issue with, the biggest issue and the biggest fear of anybody that had used balloon pumps frequently is, the balloon doesn't function well. One, the balloon gets perforated. Very rare, but it happens. And also, the more common of the above mentioned complications is the migration of the balloon pump. And if your balloon goes a little more proximal, then you're occluding perfusion to the left part of your brain and side. So important to monitor and make sure that it's placed appropriately. And like I mentioned in the beginning, each of my slides could be a presentation of its own. We have a lot of details in the chapter in the book. I will try to fly as quickly as possible without extra details to emphasize the outcomes of those studies. Shock study is the largest one that we have that involves intraaortic balloon pump. It is randomized. And what I wanted to compare, obviously, at the time was balloon pump versus, with thrombolysis versus thrombolysis alone. In patients that are acute coronary syndromes and cardiogenic shock. And can I go back? Sorry. The, it did acknowledge that there is a lower mortality. And the one thing is, it's an early study. And I will emphasize again, we have evidence of lower mortality. Then we go further throughout the years, and we are comparing the same thing. Balloon pump with thrombolysis versus thrombolysis alone. And we have a little more subspecific populations of patients that the studies are done on. But most of them are ischemic events and cardiogenic shock. There is no mortality in tactic study difference. And also, there is no mortality difference in the intraaortic balloon pump shock study, which is the same group of people that did the original one. And they looked into all-cause mortality in 30 days. And it's unfortunate for me to say that as much as we think we revolutionized medicine, the data is not behind it yet. Later, we had a registry review that basically wanted to say that even though this is a new intervention, it is percutaneous placement. But it's still intervention. The complication rate is not so high. And only, I know it's still a lot, less than 3% major complication events. The European Society and also U.S. societies came up with guidelines in 2023, literally about a month before the book, the work on the book started. And their recommendation for the balloon pump was actually only against it. Because the data doesn't show any change in outcome. The next device that we're going to be discussing is the impella. It's an axial pump. It is a device that's also percutaneously placed. It is, it actually crosses the aortic valve. And what it does is it completely unloads the left ventricle. So it takes the blood flow from the left ventricle and deposits it into the aorta. The flow rate of the device is directly proportionate to the diameter of the device. And we have devices today that can offer almost 500 res per meter cardiac output. It was also recognized as a wonderful assist device in COVID patients when they were placed on ECMO. And something to emphasize here is that most of the COVID patients on ECMO were VV ECMOs. So this was the VA component that was contributing to better management of their cardiogenic shock. Contraindications, obviously, it crosses the aortic valve. So any issues with the aortic valve, it could be considered a contraindication. If you have a stenotic valve and you decide to open it with the device, probably the outcome is not going to be good. Anything on the way for the placement of the device, because it's a larger cannula that needs to make it to the aortic valve, basically, any vascular disease that could potentially either further damage if you have an aneurysm or a dissection, or if there's too much plaque that could potentially make it challenging for the device to be placed is considered contraindications. Complications, unique to the device, it's an axial pump. So blood actually flows through the little device and it can chew up the cells. So hemolysis and coagulopathy on top of everything else as a percutaneously peripheral replacement device. Cardiac tamponade has been reported. And if you ask me how exactly can cardiac tamponade could be developed from the impella itself, I could be creative and I can come up with an answer. But there are reports of cardiac tamponade. And the data for the lowly impella. So mostly database reviews and a lot of the studies are retrospective. But it does say that there's an increased, significantly increased use of the impella device. We have it available. Now we know how to use it. It had grown to offer more and better cardiac output. The PROTECT study, too, that was published in 2012, actually compared impella 2.5. The number after the impella is basically the flow rate that you can achieve. And the balloon pump. In patients that are undergoing high-risk PCIs. So unfortunately, it did show that we have, can I go back? It did show that we have better hemodynamic improvements. However, there was no change or worsening 30-day events. Difference in major adverse events. So the proposed issue with the study was that we have a balloon pump that's doing some job. How are we going to do better when we use a more advanced device? However, the more advanced device comes with more complications. So they were able to show that there is no difference in major adverse events at 30 days. Then we have the ISOR shock study, which also compared the impella 2.5 to balloon pump. And there was, again, significant improvement in hemodynamics. And we didn't have any difference in mortality at 30 days. EMPRESS is the latest study that compared the 2.5 to the balloon pump. And those are specifically in ischemic cardiogenic shock patients. And again, no difference in 30-day and six months. Or they all cause mortality. And the same group actually published a study in 2021. They follow up the original group. And for five-year review. And there was still no change in mortality, unfortunately. More data that basically shows that we have some that improvement in the hemodynamics. And unfortunately, not so much difference in mortality. However, the registry review that covers only six years. And I do want to point out that the devices 10 years ago were different than what we currently have available. It did show improved survivor rate. And it was statistically significant. However, even the authors recognized that on the arm there was only going to have PCI. After getting the PCI done first and then the Impella placed. Basically, the Impella, there was no category. You're going to have to wait however many days before you place the Impella. There was an emergency placement of the Impella. So that probably compounded the results. And we do have recommendations in the 2023 guidelines for the Impella device. But there are no recommendations about the use. The contradications are the only reason why they were included in there. And in the beginning of my slides, the contradications were basically severe aortic disease. Those are the guidelines from 2023. TandemHeart is the next device that we're going to be discussing about. It is an extracorporeal centrifugal pump. It is physically a device that stays external to the patient. What it does is completely unloads the left ventricle. It is placed percutaneously as well through the usually most commonly the femoral vein. It passes, it goes into the right atrium. And then it transfers the atrial septum. And it goes to the left atrium where it sits. And what it does basically is it, how does it unload the left ventricle? It takes the left atrial blood, pumps it through the device and then returns, it could be returned either back to the femoral artery or it could be returned centrally. It does, can generate flows up to five liters a minute, which is basically normal cardiac output. And could be placed by the bedside. I don't know about many of you how many, what type of practices you have. Cardiac teams can place it in cath lab very quickly as well. Indications, it's not the first line of placement when we think about we need something, somebody is in acute coronary syndrome and we can place a device immediately by the bedside because it does need confirmation of placement and it probably needs a C-arm that is not as easily available as we're going to place it and then we're going to confirm with echo or we can go to radiology to confirm placement with the prior two devices. Contraindications, so the big thing about the tandem heart basically is that if you have any clots in the central system, it's going to be contraindicated because it's a pump. It will create a suctioning event and it can occlude the pump and it's going to malfunction. Complications, again, peripherally inserted, lymph ischemia associated with, sorry, insurgent sites. The challenges with the tandem heart is that it crosses the septum. So you have created an ASD, functioning ASD. And the issue is that if you have a lot of movement, then you can migrate the device and that's the biggest fear because then you can create, you're not having the VA unloading of the ventricle. And for that reason, people are usually, patients on tandem heart have to be on bed rest. Those are not the people that are going to be walking the whole way. Data about tandem heart, we do have some available and unfortunately, as much as I want to tell you, this is a newer device that's supposedly a better device, completely unloads the left ventricle, I cannot convince you that it shows improved outcomes. And also, we are starting to see more complications associated with this device. But I do want to emphasize, again, that this even though it is still percutaneously placed, it is an extracorporeal device unlike the previous devices we've discussed. I will, every slide is going to say that hemodynamically it's better. But however, I cannot prove evidence for improved outcomes. Survival, excuse me, survival. And the 2023 guidelines basically recommended against using tandem heart if you have a left atrial thrombus for the reasons that I mentioned previously. As I am moving down the line, we have the VA ECMO. So truly extracorporeal pump, basically. And in addition to just pumping the blood, it offers a membrane oxygenator. It was discovered by, after the cardiopulmonary bypass was utilized in the 50s, basically, the engineers at the time figured can we just keep people longer on a bypass machine and being able to recover their hearts and stay for days, hours. And at the time, it was hours and days and some people survived it either. But as technology got better and better, we were recognizing that we can basically do, we can support the right, the left side. We can support the lungs as well. It could be placed percutaneously as well. It could be done surgically, centrally cannulation. The flow rates that are the latest machines are as high up as, can I go back to the previous slides? Apparently I'm talking too much. Flow rates is up to eight liters, which is exceptional cardiac output, as you can imagine. Indications are anything, basically, the left side, the right side failure or the lungs. And during COVID, we actually have recommendations for use of ECMO as extracorporeal CPR with a very subspecific group of population. Contraindication, that is a long list of contraindications. What I want to summarize about that is that, obviously, you have to pick the right candidate for going on ECMO. And in my opinion, being able to have cardiac recovery or being qualified for transplant should be high up on the list because if we cannot either recover the heart or offer you long-term survival, then the point of ECMO is really just super temporary. And poor life expectancy and the rest of the conditions, as you can read, which is basically, I included VV ECMO just for being complete because the recommendations are not much different for VA versus VV ECMO. Complications, the same thing. We can have surgical complications, insertion site complications, limpid ischemia, which could be avoided by actually having a reperfusion cannula. Too much of details. Hemolysis, obviously, it's a completely extracorporeal circuit, so all the cells could be chewed up. Metabolic derangements associated with that. What also the technique and the art of being able to come off the ECMO, basically, is when how do we allow the native cardiac function to recover and there's a lot of arguments in the expert field that by supporting the heart for too long or too much, basically, we're not allowing the heart to assume its native function. The data available for this thing. So, meta-analysis, I understand it's not a randomized control trial, but it's the data that's currently available. After cardiac arrest, in cardiogenic shock, basically, VA ECMO versus supportive care, it did improve survival. We did have better rate of neurological recovery. Actually, and then, also, what they acknowledge, and this is a review, again, I'm sorry, is that about 30%, one-third, basically, had a better survival, 30-day survival, VA ECMO versus intraaortic balloon pump. And also, again, disappointment on my end, but I cannot convince you that people on ECMO did better compared to, can we go to the previous slide? People on ECMO did better than the tandem heart of the impella, which if I have to interpret that finding, and you can argue that I'm biased for support, is that the tandem heart is an extracorporeal system, basically, doing similar job, not being able to accomplish the level of cardiac output that you would want. Impella, in a way, is unloading it differently, but also with an appropriate cardiac output, maybe that's the reason why the outcomes are not different. Again, speculation on my side, and I'm absolutely biased. 2023, the ECMO trial, CS cardiogenic shock was published as well, VA ECMO versus conservative management, and again, unfortunately, there was no difference in mortality. But also, there was no difference in severe adverse events. I know that this was the author's idea of saying, hey, we understand maybe mortality is not better, but we also don't cause more damage. Can I go back again? Thank you. Sorry for that. This was a study done 10 years ago by now, as you can imagine, so the data that we have today wasn't available at the time, but the Sakamoto compared global physiological functioning and also outcomes at one in six months in out-of-the-hospital arrest patient for extracorporeal CPR, and they did say that people neurologically do better at one month and six months if we utilize ECMO versus the standard CPR. Also, Kawakami found out that the time to ECMO matters, so maybe we can improve outcomes if we are able to get to the support device faster, and a review of a national database basically for almost 20 years, but it was also 20 years ago, is that we have increased the use of ECMO now that we have it available. We have more centers. We have more providers that are able to initiate it quicker. We have hubs of hospitals that can provide the whole service, and also it did show some decreased mortality. I do want to emphasize that it was a review. The 2023 guidelines that are ECMO related are basically, first of all, if anybody wants to consider using ECMO, we should consider implementing shock teams. Then we should probably concentrate on if a hospital is a higher level of care or acuity to consider it an ECMO hub, then they should be initiated as quickly as possible, any assist devices, and also we should consider it for people that are receiving cardiopulmonary resuscitation already, and at the very bottom, and I've underlined the recommendation for, before you put somebody on ECMO, consider can you reach this hemodynamic parameters, and those are numbers that all of us had seen that had been available in data from the past, cardiac index certain number. I'm not going to waste your time with the numbers, but there are recommendations for when to use ECMO. We do have mechanical support on the right side, which is basically similar than the left side. This is a little bit of data. Why are we interested in the right side? Even though it's very rare, it does happen. Now we have also people that are leaving and walking around amongst us with left permanent devices, and some of them unfortunately experience right failure. They need support, so we're figuring out how to support the right heart independently. I'm sorry I'm going faster because I think I'm getting short of time already. Indications, basically very similar, right heart support, mechanism of action, the same devices that I just discussed with you, basically the impella, the RP, and also a Protec Duo is a special cannula that allows us to support the right heart as well, and the ECMO are going to be the devices that are going to be supporting the right heart. And right heart support is needed if you have either left device that is precipitating the right failure, you need both chambers to be supported, or you have respiratory failure that needs to be supported. The data that is available behind the right side, I do want to emphasize that those are absolutely independent groups that did all the studies. But if you notice that the 70 to 73% survival rate is everywhere, and we do have improved hemodynamics and not necessarily better survival rate, but 70% survival rate. And there is more studies done later that also mention the 70% survival rate. So as much as I want to tell you improve, serve, do better, I cannot make that statement, but it's a good survival rate if you have a right assist device. And the 2023 guidelines actually address the right side as well. It says that those are the two commercially available, basically the Protec Duo, which could be placed by the bedside and also Impella, which is the right side supported, could be considered in acute right ventricular failure. And something that they actually implemented is that for somebody that doesn't have a left support device and the right is the primary, always make sure that we're not precipitating a left failure. So to keep in mind, those are the only right-sided recommendations from 2023. This is my favorite slide of the presentation. And please don't be offended. This is basic physiology. Randy, my resident, told me not to spend more than three words per figure, per VP loop. So I wrote down what I'm going to say, because otherwise I can spend a whole day talking about this thing. And I'm also color challenged, so bear with me. In the regular gray, the chunkiest of the loop, that's normal VP loop. This is how the heart should look like, or if you place it on a VP axis. Then in cardiogenic shock, which is dark blue, purple, however you want to see it, see how everything is shifted to the right. Basically what it tells us is that our left and the isolated pressure is elevated, and our stroke volume and EF are respectfully decreased. Then we decided to place an intra-aortic balloon pump in the cardiogenic shock, and it is the red VP loop that's slightly to the left of the cardiogenic shock. That left shift actually tells us that we were able to decrease the level of trigger preload a little bit, and we were also able to make the heart a little more efficient, so our stroke volume is better. Then I have the light blue triangular shape impeller device. This is very specific to the impeller, the triangular shape, because what we are missing from the loop is there's no isovalimetric relaxation and contraction, because the device, remember, is crossing the pump. It's crossing the aortic valve, so there's not physiological opening and closing of the valve as well. So what it did is it shifted it completely to the left, telling us that we were able to unload the ventricle way better, and our solid pressure was better, and we were able to improve, again, stroke volume and ejection fracture. Then I have the green loop, which is the tandem heart, and this is a tandem heart that is unloading the left ventricle from the left atrium to the femoral artery. The loop is narrow. We have decreased end diastolic pressure, which is, again, a good indication we're unloading the left ventricle. We have some increase in the left ventricular and systolic volume as well. We have a little bit of decrease in stroke volume, and part of that is because the native heart function has the decreased stroke volume because the pump is actually doing all the work for that, and we also have an increase in aortic pressure, and that's because now we have better systemic blood flow. The last one is basically a peripheral ECMO, and that's the yellow one that's up most to the right of the curve. It has increased left end diastolic pressure and also increased aortic pressure. Again, better systemic flow. We have lower stroke volume, and the reason for that is the pump is doing most of the work, and that's as fast as I can go on this slide, but the reason why I have this there is because we really, if we understand what the patient needs, we can choose appropriately what device they need to serve the purpose of their hemodynamics, and as much as I really want to tell you we're going to improve mortality, I cannot prove that to you today. Good table with all the devices. I'm not going to waste your time right now on that, but I do want to emphasize that up to impel about 5.5, all those are in French, so we place central access with the same size by the bedside every day. They will become more and more easily available and placeable. Again, that's for your reference. Some shared complications of all the devices. We discussed the most specific one and unique to the device, per device. Special circumstances is something that I want to go as quickly as I can. Peripartum patients, we kind of touched based on trauma already on that, and I feel like it's important for us to discuss because we're seeing that and we're utilizing, we're applying the same guidelines for hemodynamic management, for trauma management to the peripartum patients. So why not mechanical support? The issue with pregnancy obviously is a lot of physiological changes and cardiogenic changes are very significant actually. They can double their cardiac output and it can last up to six weeks after delivery. So they're a special group that we need to pay attention to. Most common causes for cardiogenic shock and heart failure in peripartum patients basically is cardiomyopathy and pulmonary embolisms. We have data available. It's not as much as we want to, but we certainly have that. Old studies registry up to 2014, as you can see, that we have increased use of mechanical support for peripartum cardiomyopathy without changing mortality. Again, I cannot prove to you that we do better in that regard. However, when they did secondary analysis, they discovered that if we're able to diagnose and go to the mechanical device sooner, then we have changing outcomes. Also, we had long-term serious studies published in 2022 and it followed a total of 13 patients that were placed on mechanical support. One unfortunately passed for different reasons. Five of them received transplant and seven of them recovered. So I think part of this actually helped with the guidelines, the 2023 guidelines. And in the review of the InterMAC database, and you had a good number of patients that were reviewed basically. Unfortunately, only 99 patients out of almost 1,200 patients had to be placed on mechanical support secondary to cardiomyopathy. But they did do better for the two-year outcome. And part of the reason for the author's explanation was that those are usually young, healthy people. And if they only have isolated cardiogenic shock that was precipitated by their pregnancy, obviously they're going to do better. The guidelines for 2023 concerning peripartum patients, actually it says that they should receive acute mechanical circulatory support. It should be considered as breach to recovery. And also, when you are taking care of those patients, MFM has to be consulted. Trauma is the next subset of patients that I quickly want to touch base on. First trauma patients that utilized ECMO was in the early 70s. And it was a VV support. The issue with the trauma patients, obviously it's the coagulopathy. And in the past, it was considered to be a contraindication to even consider placing a patient on an ECMO device. And sadly, I want to say that less than 1% of the trauma patients, that all patients that have been on ECMO are trauma etiology. Multiple studies to review what we do when we have trauma patients and we place them on ECMO. And as you can see the numbers, we, most of them, close to 90% are basically for respiratory failure. And the rest of it is basically two-thirds or cardiogenic shock, secondary to cardiac failure, or basically arrest. And survival, not surprisingly, is respiratory failure. It provides you VV ECMO, offers you the best survival. And I cannot say that it's the ECMO that is offering the survival. I think it's the etiology of the reason why you went on ECMO. And something to, specific to the trauma patients, even though there's always bleeding complications in the ECMO circuit, 29% have bleeding issues, again, to go back to the triad with coagulopathy being part of the triangle. More data available, and this is basically to investigate how people are anti-coagulating the trauma patients and to remind us, having an extracorporeal circuit, plastic tubing, basically. People have to be anti-coagulated, and different institutions have different protocols for that anti-coagulation. So what Wudetal found out, basically, is that 35% of patients that were on ECMO were not anti-coagulated, and they actually did okay. And they also had less complications. They had less heat issues, and there was no difference in thrombosis or difference in mortality, again. Maybe that will change the idea of next time we have one of our patients, the case today, to consider going to circulatory support earlier than later. This was a systemic review of reports, and what was found by Badir was that there were only four reports of heparin-free ECMO, which is impressive, and the time on ECMO was actually super short. There were five reports with ACT time less than 180, which a lot of institutions nowadays are actually using that, and there were no reported complications secondary to either thrombotic events or need to change the circuit. Thank you. Or changing the circuit more frequently. So perhaps the future for the trauma patients would be to consider changing the anti-coagulation guidelines if we need them to be on mechanical support. The next category of patients that could benefit from mechanical support are actually the community-induced cardiomyopathy incidence is relatively high, if you ask me, reported between 1 to 5%, and also something that I wasn't aware until I started looking into the specifics. Basically, up to 20% of patients that are undergoing chemotherapy could have asymptomatic ventricular failure that we're not even aware of that. It is a bimodal disease, so it's either during early, during the beginning of their chemotherapy, or it can happen later after they finish their chemotherapy. And also, it could be temporary or permanent, unfortunately. And they're a special subgroup of patients because they don't qualify for transplant soon after their chemotherapy. A lot of different type of cancers require 3 to 5 years of remission before it could even be considered for a transplant. And usually, the more permanent devices have been used in this subcategory of population, not so much the acute devices. Data available for specific to chemotherapy-induced cardiomyopathy is the Intermax Review 2014. Basically, only 75 patients of 3,000, this is less than 2% of the patients that were on ECMO at the time were basically for chemo-induced cardiomyopathy. And what they compared basically was the chemotherapy-induced cardiomyopathy, the ischemic cardiomyopathy, and the non-ischemic cardiomyopathy. And as you can see, the chemotherapy-induced one required, those were the patients that required the most right support on top of their left support, and also kind of risk of bleeding and no difference in mortality. You will keep hearing me multiple times that unfortunately, there's no difference in mortality. The next category of population that is a little different than the general population is the adult cardiogenic heart disease. And I feel like there was a slide that got missed. Can I go one back? Basically, we have nowadays people that are adults living with congenital disease, and we know that they're getting more and more because the procedures they were able to offer now are more complicated and more easily available. But we should not classify them as one group of congenital heart disease because they're very different physiologies and very difficult procedures, but we have no means of how else to classify them. The data available is basically that their outcomes are very similar as the general population outcomes. 2023 guidelines addressed the specifics, and I don't want to take too much time because it's too specific, but one thing is if it's a full-time procedure as a child and basically impella and aortic balloon pump may be not a good device. Reason being is too close to where the procedure was, and also good neurological evaluation prior to deciding if you want to go into more permanent device. Excuse me. Bridging therapy to heart transplant. In 2018, the UNOS changed their schema for heart transplant, basically allowing more people to be in group 1A and allowing to use acute devices for the 1A group. So the number of people in 1A group significantly increased, but also, we were able to offer, allow them to have longer week period time just because they were able to have acute devices, and as you can see, a little bit of data here is that people were breached. Thirty-three percent of balloon pumps were breached through transplants, and only 12.4 of ECMO in out-of-temporary devices. That is data from 2018. That is for prior years, so I do want to think. I mean, this is only my thought. Unfortunately, I have no evidence for that is that this number is going to change if we do the same study 10 years down the road just because of the application of the newer devices. We don't have necessarily improved outcomes, as you can imagine, but their hemodynamics are better. So if you put somebody on temporary device before you choose to make, to put them on durable device, they actually hemodynamically do better. So again, maybe they can stay on the list a little longer before they're able to get their transplant. I'm getting close to the end. Future directions, I think, is where everything is what we do in medicine, right? Discover the data and decide what you're going to do so you can apply it and hopefully cure disease. And the biggest conclusion for me today is that where's the future of mechanical support? I think it's multidisciplinary teams, just like we have stroke teams, and we have shock teams, and we have STEMI teams, and also, I'm sorry. Can we go back? And does it improve outcome? Actually, we have evidence that it does improve outcome. And I will tell you that University of Utah, 2015, that's almost 10 years ago, they developed their shock team, and they actually have evidence that they improve outcomes to hospital survival 30-day if the team is available to manage those patients. And they also, their secondary outline, basically, analysis was that it was irrelevant of device. There's not one device that does better than the other. In another group, published in 2021, Papoulos actually did the same thing. They looked into cardiogenic shock in hospital institutions where they have shock teams and they don't have shock teams. And it does show that shock teams actually, people have improved survival. One, secondly, less mechanical devices are being utilized, but where devices are being utilized, they're the most advanced ones. So I think the expertise of the group makes a difference. And this is where my colleague, Dr. Badani, actually did an amazing job during COVID. And he established protocols in his institution, how to establish an ECMO program. It's also a presentation by itself, but the five pillars of establishing the program is basically you have to establish a need. You have to be large enough institution to be able to say, hey, I have a lot of patients and also I have all of the disciplines that I need to establish this team and I can establish it. Getting institutional buy-in, all of us know how difficult it is to convince the business people that we need the money invested because it's very expensive. But it's also something that from the very beginning to the very, from the patient getting into your hospital and then leaving your hospital and outpatiently even, it would bring a lot of money to the hospital institution as well. Resources, obviously it's very high intensity resource endeavor, something to consider. You can't just have a good surgical department or a good cardiology department. You need your ICU, you need your OR, you need your IR, you need everybody available. Initial and continued education, ELSO is the group that offers education for mechanical support. And if you choose to establish a team, basically within your system, you can register with them and they will guide you through the process. And once you become a member, obviously continuing education and consistently rechecking and quality improving everything that you have currently available. ECMO during a pandemic, VV ECMO become popular in 2009 H1N1 and had a lot of data available for us to move the VV forward. I think COVID is going to do that for VA ECMO and we already have changes that are happening. The number of ECMO patients worldwide since the beginning of COVID was 17,000 at the time of me doing this presentation which was about a month ago. What I am hopeful for is that we're going to have data, we're going to be able to make conclusions and hopefully change guidelines and improve outcomes. Complex entity, right, we don't know exactly how to define it but we know it's complex cardiogenic shock. We also know that we have mechanical devices that we can use for that. We have not as much data for the newer devices but I'm hopeful that it's going to come. Mortality is high even with the most contemporary management that we have available. What I can publicly make a statement is we do have improved outcomes with early implementation. So what do we do about that? Create shock teams and centers. I will repeat myself again, risk stratification and prognostication, I think this is where the future of anything is basically. And what can we do about the engineering of the devices in the future? Well, you can probably, there are more creative minds than me here right now that we can do smaller size devices, longer battery, less cables, minimally invasive techniques that could be done by the bedside, by the intensivist, instead of needing to call in a surgeon to do that. Anticoagulation needs the better plastic material we have, maybe the less anticoagulation we have to do. And I know this sounds very futuristic but can you imagine if we have a smart pump that can respond to hemodynamics just like the pacemakers can do that? And I'm pretty sure that engineering companies are working on that already. Larger trials, so we can do, hopefully, proof, better outcomes and actually improve guidelines. And shock teams and hubs because they definitely make a difference. And I do want to thank you for being here and listening to me today. Thank you.

mechanical circulatory support devices

cardiogenic shock

multidisciplinary shock teams

device technology

early implementation

risk stratification

smart pump technology

research