Abstract Aims Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly being used to support patients in cardiogenic shock (CS). Early determination of disposition is paramount, as longer durations of support have been associated with worse outcomes. We describe a stepwise, bedside weaning protocol to assess cardiopulmonary recovery during VA‐ECMO. Methods and results Over 1 year, we considered all patients on VA‐ECMO for CS for the Weaning Protocol (WP) at our centre. During the WP, patients had invasive haemodynamic monitoring, echocardiography, and blood gas analysis while flow was reduced in 1 LPM decrements. Ultimately, the circuit was clamped for 30 min, and final measures were taken. Patients were described as having durable recovery (DR) if they were free of pharmacological and mechanical support at 30 days post‐decannulation. Over 12 months, 34 patients had VA‐ECMO for CS. Fourteen patients were eligible for the WP at 4–12 days. Ten patients tolerated full flow reduction and were successfully decannulated. Twenty‐four per cent of the entire cohort demonstrated DR with no adverse events during the WP. Patients with DR had significantly higher ejection fraction, cardiac index, and smaller left ventricular size at lowest flow during the WP. Conclusions We describe a safe, stepwise, bedside weaning protocol to assess cardiac recovery during VA‐ECMO. Early identification of patients more likely to recover may improve outcomes during ECMO support.

Purpose With increased use of venoarterial extracorporeal membrane oxygenation (VA ECMO) to support patients in cardiogenic shock (CS), protocols for weaning and assessment of recovery are required. We describe a stepwise, bedside weaning protocol to assess cardiopulmonary recovery during VA ECMO. Methods All patients on VA ECMO for CS were considered for the Northwell Weaning Protocol (NWP). 24 hours before NWP, pulmonary toilet and fluid balance were optimized. Full ventilator support and dobutamine 3-5µg/kg/min were initiated prior to the protocol. Patients had invasive hemodynamic monitoring (arterial, Swan-Ganz), echocardiography, cerebral oxygenation and blood gas analysis. aPTT was maintained > 50s prior to NWP and ACT maintained > 200s when ECMO flow was reduced < 3 LPM. Flow was decreased in 1 LPM intervals and data acquired after 5 min at each stage. At ECMO 2 LPM, Impella/IABP support was minimized. After 1 LPM, the inflow line was clamped (15s flush every 5 min) for 30 min and final measures taken. Durable recovery (DR) was defined as being free of pharmacologic and mechanical support at 30 days post explant. Results Over 8 months, 25 patients had VA ECMO for CS. Eleven patients underwent NWP at 4-12 days (14 not stable for NWP). Eight of 11 tolerated flow reduction and were successfully decannulated for recovery. Of these, 5 had DR and 3 did not (2 durable LVAD, 1 died). Patients with DR had significantly higher EF and smaller LV size, and tended to have higher cardiac index and mean arterial pressure at lowest flow during NWP (Table 1). Patients with DR also tended to have shorter durations of ECMO support. No adverse events occurred during NWP. Conclusion We describe a safe, stepwise weaning protocol to assess recovery during ECMO support. In this cohort of patients, 20% demonstrated DR. Echocardiographic and hemodynamic measures at lowest flow identified patients who went on to demonstrate DR. Formal weaning studies can help guide decision making in this challenging patient population.

IntroductionMost heart failure (HF) programs use a subjective provider assessment (SPA) of frailty, or "eye-ball" test, for patient selection for advanced therapies (AT). The Modified Fried Frailty Index (mFFI) is an objective assessment of frailty and has been validated in elderly HF populations. We compared SPA to mFFI in patients referred for AT.MethodsPatients referred to our center for evaluation for AT were studied. Those unable to undergo mFFI testing due to other comorbidities were excluded. mFFI assigns a frailty point in each of five domains (max. possible score 5): weight loss, exhaustion, activity, walk time, and grip strength. Patients are designated as frail when score ≥3. Additionally, three cardiac surgeons independently determined patients to be frail or not frail (SPA). Surgeons were blinded to designations given by the other surgeons as well as to the mFFI score. Patients who underwent LVAD implantation were reevaluated with the mFFI at 3 and 6 months.ResultsOver 12 months, 30 patients (59±13 yrs) were studied. All patients were assessed by at least one surgeon, 27 by at least two, and 13 by all three. Comparing frail to not frail cohorts (by mFFI), frail patients were older, had lower albumin, and smaller LV size. SPA significantly underestimated frailty compared to formal mFFI testing (0-18% vs. 63%, p<0.01) (Fig. 1A). Correlation between SPA and mFFI was not strong (38-59% agreement, κ< 0.25). However, agreement between providers was robust, with any two providers agreeing 83-93% of the time, and when all three assessed a given patient, agreement was 77% (W= 0.49). Importantly, providers never designated a patient to be frail when they were not frail by mFFI (Fig. 1B). Six patients underwent LVAD implantation and had follow-up mFFI assessments. Frailty scores improved in all patients after LVAD such that at 6 months, the maximum mFFI score was only 1/5.ConclusionWhile agreement between providers is strong, subjective assessment significantly underestimates frailty when compared to formal testing. Notably, providers were always accurate when they designated a patient as frail. Frailty scores improved in all patients after LVAD, suggesting reversibility of the frailty syndrome. Further study of frailty assessments in advanced HF may improve patient selection for AT.

Assessment of frailty is key for evaluation for advanced therapies (ATs). Most programs use a subjective provider assessment (SPA) or “eye-ball” test; however, objective measures exist. The modified five-item Fried Frailty Index (mFFI) is a validated tool to assess frailty. We compared SPA to mFFI testing in patients referred for AT. We also compared levels of macrophage migration inhibitory factor (MIF), an inflammatory biomarker associated with worse outcomes in heart failure, between frail and not frail subjects. Seventy-eight patients referred for evaluation for AT underwent both SPA and mFFI testing. Three cardiac surgeons independently assessed patients for frailty (SPA). SPA significantly underestimated frailty compared with mFFI testing and correlation between SPA and mFFI was not strong (κ = 0.02–0.14). Providers were correct 84% of the time designating a subject as frail, but only 40% of the time designating as not frail. Agreement between all three providers was robust (76%), which was primarily driven by designation as not frail. There was no significant difference in plasma MIF levels between frail and not frail subjects (47.6 ± 25.2 vs. 45.2 ± 18.9 ng/ml; p = 0.6). Clinicians significantly underestimate frailty but are usually correct when designating a patient as frail.

Introduction: Assessment of frailty is essential for determining eligibility for advanced therapies (AT). Most programs use a subjective provider assessment (SPA) or “eye-ball” test. The Modified F...

Purpose Both macrophage migration inhibitory factor (MIF) and angiopoietin-2 (Ang-2) have been linked to poor outcomes in cardiogenic shock (CS). These proteins are rapidly released from intracellular storage and have profound effects on the cardiopulmonary vasculature. We describe the changes in plasma MIF and Ang-2 in patients with CS supported with VA ECMO. Methods All patients supported with VA ECMO for CS in our center were enrolled. Blood samples were drawn at the following time points: within 24 hrs of ECMO (baseline), at 72 hours, and on the day of the weaning study (4-12d). MIF and Ang-2 were measured using commercially available ELISA (R&D Systems Inc., Minneapolis, MN). Results Twenty-three ECMO patients were studied. At baseline, both MIF and Ang-2 were significantly elevated compared to controls (n=9) (455±514 vs 1.5±0.7 ng/mL, p<0.001, and 48±75 vs 3.3±0.7 ng/mL, p=0.009). Both MIF and Ang-2 decreased on ECMO (Figure 1). At 72 hours, there was a significant decrease in MIF compared with baseline (74±42 ng/mL, p=0.035). Similarly, Ang-2 levels had significantly decreased by the day of weaning (12±7 ng/mL, p=0.038). Five patients had durable recovery (no pharmacologic or mechanical support at 30d post explant). In these patients, baseline MIF levels were significantly lower than those without durable recovery (113±35 vs 555±547 ng/mL, p=0.004). Conclusion CS is associated with significant derangement of plasma MIF and Ang-2 that improves with circulatory support. Importantly, patients who recovered had lower levels of MIF at presentation. Further study of these mediators may identify novel targets for therapy in cardiogenic shock. Both macrophage migration inhibitory factor (MIF) and angiopoietin-2 (Ang-2) have been linked to poor outcomes in cardiogenic shock (CS). These proteins are rapidly released from intracellular storage and have profound effects on the cardiopulmonary vasculature. We describe the changes in plasma MIF and Ang-2 in patients with CS supported with VA ECMO. All patients supported with VA ECMO for CS in our center were enrolled. Blood samples were drawn at the following time points: within 24 hrs of ECMO (baseline), at 72 hours, and on the day of the weaning study (4-12d). MIF and Ang-2 were measured using commercially available ELISA (R&D Systems Inc., Minneapolis, MN). Twenty-three ECMO patients were studied. At baseline, both MIF and Ang-2 were significantly elevated compared to controls (n=9) (455±514 vs 1.5±0.7 ng/mL, p<0.001, and 48±75 vs 3.3±0.7 ng/mL, p=0.009). Both MIF and Ang-2 decreased on ECMO (Figure 1). At 72 hours, there was a significant decrease in MIF compared with baseline (74±42 ng/mL, p=0.035). Similarly, Ang-2 levels had significantly decreased by the day of weaning (12±7 ng/mL, p=0.038). Five patients had durable recovery (no pharmacologic or mechanical support at 30d post explant). In these patients, baseline MIF levels were significantly lower than those without durable recovery (113±35 vs 555±547 ng/mL, p=0.004). CS is associated with significant derangement of plasma MIF and Ang-2 that improves with circulatory support. Importantly, patients who recovered had lower levels of MIF at presentation. Further study of these mediators may identify novel targets for therapy in cardiogenic shock.