Retrieval of Patients in Severe Cardiogenic Shock with Mobile Extracorporeal Life Support (ECLS) Implantation and Subsequent Air- or Ground-Based Transport

 

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Objectives: Venoarterial Extracorporeal Life Support (ECLS) emerges as a salvage option in therapy-refractory cardiogenic shock but is limited to highly specialized tertiary-care centers. Critically ill patients are often too unstable for conventional transport. Mobile ECLS programs for remote implantation and subsequent patient retrieval could solve this dilemma and make the full spectrum of advanced interdisciplinary cardiac care available to patients in remote hospitals in whom cardiogenic shock otherwise might be fatal. Here, we describe our concept, protocol as well as clinical results and outline how to establish a supra-institutional rapid-response ECLS program.

Methods: Support is provided 24/7, the team consists of an experienced cardiac surgeon and perfusionist, is ready to depart within 5 to 10 minutes during working hours and a maximum of 20 to 30 minutes on call. Compact support systems designed for transport are used; implantation is performed bedside percutaneously with no imaging modalities being necessary. All material is taken rendering the team self-sufficient and independent of local circumstances. Retrieval is feasible air- or ground-based whereas technical pre-requirements and for air-transport compliance with specific regulations need to be taken into consideration.

Results: From 12/2012 to 03/2016, a total of 40 patients (20.0% female, mean age 55 ± 10 years, INTERMACS 1.30 ± 0.46) underwent venoarterial ECLS implantation in remote hospitals with subsequent ground-based (n = 29, 72.5%, mean distance 27.9 ± 29.7 (5.6–107.1) km) or air (n = 11, 62.4 ± 27.2 (38.9–116.4) km, respectively) transport to our center. Predominant etiologies were acute coronary syndrome (55.0%) and decompensated cardiomyopathy (15.0%), 70.0% had been resuscitated, in 17.5% implantation was performed during ongoing CPR. In 52.5%, the referring hospital was closer than 25 km to our center, in 20.0% more than 75km away. With gaining experience more air transports were performed. No ECLS-related complications occurred during transport. The ECLS system could be explanted in 65.0% (n = 26), 30-day survival was 52.5% (n = 21).

Conclusion: Remote ECLS implantation and inter-facility transport on ECLS for retrieval of patients in intractable and potentially fatal cardiogenic shock is feasible, efficient and effective. Strict protocols and standards ensure an organized approach and increase safety. A well-trained team and interdisciplinary consecutive patient care are required to achieve optimal outcome.