 Todd Barrett, a faculty member at Cedars Sinai in Los Angeles. He graduated from the University of Kansas School of Medicine and did his internal medicine in pediatrics, combined residency here at the University of Chicago. In 2013, he headed to Harvard University for a Palliative Medicine Fellowship with a focus in pediatric palliative care. And he's going to talk to us about ECMO. So I'm going to start off today with my talk about ECMO. I have no financial disclosures. To talk a little bit about the institution I'm coming from, Cedars Sinai, I've only been there for a very short time. But we have one of the now the largest volume cardiac transplant programs in the world. Since we started our cardiac transplant program in 2008, we just completed our 100th cardiac transplant. And we've done, we actually have done six this month. So just some of the objectives for my talk, I want to review mechanical circulatory support devices and their indications. Kind of piggybacking off the talk earlier in the conference. Show the increase in incidence of ECMO utilization. Present preliminary outcome data from our experience at Cedars from 2007 to 2013. Discuss some unique ethical dilemmas related to ECMO and end of life. Give you three real life examples of how this is occurring in our hospital and how it relates to real life. And focus attention on areas of clinical ethics need and research. So to just kind of review some of the devices again, this is a left ventricular assist device. As mentioned before, there's kind of an outflow track from the left ventricle. And there's a device that supports circulation to go back into the arterial system. This extends life when there's univentricular failure. And this, as mentioned earlier, there are bridge therapies or destination therapies. So for patients with advanced heart failure that have really severe symptoms, this can augment their circulation to improve quality of life and length of life. But this can also be used for younger patients that are bridging to transplant. Next is ECMO or extra corpuscular membrane oxygenators. And there's really two kinds of ECMO. There's VV ECMO and VA ECMO. So as you'll see on the left, VV ECMO. For all intents and purposes, I want you to think of this as lung bypass. So we basically, for patients that have severe acute lung injury, we can take blood away from the venous system, oxygenate it, return it to the heart so that the heart can then provide oxygenated blood flow to the rest of the body. On the other case, VA ECMO, this is sort of heart lung bypass. So for patients that have decreased lung function as well as decreased cardiac function, we take blood away from the heart, oxygenate it, and then under pressure return it to the arterial system so that they can have adequate cardiac output. These carry different rates of success. And they also carry different rates of complication, mainly with VA ECMO that any clots that form in that machine go directly into the arterial system, which causes a really high rate of stroke. So some of the indications for ECMO are acute respiratory distress syndrome, like we spoke about. And this actually has a pretty decent success rate, as witnessed in H1N1 with VV ECMO. But also, severe cardiogenic shock, post-cardiac arrest, and post-cardotomy failure to wean from bypass. And really, we think of these patients as progressively sicker patients that have progressively worse prognosis when they're on ECMO. The next technology that we're starting to use a lot, especially at our hospital, is the total artificial heart. So this is a device where when you have biventricular failure that we can't use just that LVAD device, we actually remove part of the ventricular tissue itself and implant two pneumatic pumps to completely take over function of the heart. So in this case, there's actually no intrinsic function of the heart left. You just have the pneumatic device. So in thinking about the real-life schematic of how this works, a patient comes in in shock and is initiated on ECMO. And there's a few paths that this can take. Patients either recover or they die. And those are the two extremes. But there's actually a small group of patients in the middle that will progress to a more definitive therapy. Because ECMO is a technology that really only takes place in the ICU setting. It's not a mobile technology that you can take with you outside of the hospital. So the LVAD is something for somebody that has univentricular failure that can either go to destination therapy or transplant. And the total artificial heart are for the sicker patients that really have minimal cardiac function so that they can be ambulatory to get to a transplant. Or they also can have complications and die with a total artificial heart. So this is just to show the rise in incidents of mechanical circular story support cases. So I don't know if this works. But you'll see the red line is the total incidence of cases that we have from year to year. And it's an exponential increase. And I also, you'll see the blue line, there's a steady increase in these left ventricular assist devices as there's more and more people mobile in the community using them. But the cases I really want to point out are the green and the black cases. The total artificial heart in ECMO that is just taking off in the last 12 months. So this is looking at some of our total outcome data for mechanical circulatory support. We've done almost 250 cases looking at LVADs, TAH, and ECMO. And we have quite a few that are living a pretty decent quality of life in the community with ongoing therapy. But I do want to reflect on the other spectrum with a bridge therapy on this technology. We have almost an equal probability of death and transplant. And if you break these down even further, we'll look at the LVAD cases, which I want to give a disclaimer here. This is a little bit skewed because we have many, many people doing well with ongoing therapy that over time, as they die with their device, get filtered into the death category. But we also have a lot of people that have progressed to transplant. But then I want to shift our focus up to the ECMO case that's just taking off. And in this, you'll see that there's a really high rate of hospital mortality. But at the flip side, especially with VV ECMO, patients are getting better. Some of these patients are walking out of the hospital. So this is sometimes a really hard dichotomy to assess. So in just thinking about some of the ethical issues of initiating something like ECMO, this is a technology that can really these days be inserted at the bedside with a percutaneous method. It's almost always initiated in a crisis with a nonverbal patient. These are patients that have a sudden cardiac arrest. They have an arrest or severe cardiogenic shock in the community and that are flown into a quaternary care center. And we initiate this in a crisis. There's often not consent because the family hasn't arrived or the patient is nonverbal. Without ECMO, all of these patients would die. It's really when we've exhausted all medical technology that's available that we initiate these sorts of organ bypass systems. And all of these patients wouldn't be living if we didn't try. And it's only performed in quaternary care centers, which is starting to develop some disparities in healthcare because especially if I had a cardiac arrest in my hometown in Hiawatha, Kansas, I wouldn't have access to this technology. But if I had a cardiac arrest on rounds at Cedar Sinai, I ended up on ECMO in a matter of seconds. And there's also increased novel usages of ECMO. This is a problem we don't have in LA, but you definitely have in Chicago. When I was in Boston last year, there's a lot of people using these for cold drownings. So when patients come into the hospital that have minimal cardiopulmonary function, they're too hypothermic to be declared dead. They're placed on ECMO until they're warmed up so that they can determine if the patient's eligible for other therapies or if they're in fact dead. This is really complicated, especially in children when they're flown in and their parents aren't there and now they're on a machine. And we do in fact decide that they don't have any brain function, any heart function or any lung function. Now we're on an advanced circulatory support. The ethical issues in withdrawing it is even more significant. So cardiac death is nearly impossible without a circuit failure. We're providing 100% of the cardiopulmonary function of these patients and you can continue that support until they either bleed or they clot and the machine stops working. And it's also extremely possible to assess brain death. A lot of these patients will develop strokes over time and if you're brain dead on a mechanical circulatory support, one of the criteria to determine brain death is to determine if they have any intrinsic respiratory function. So in order to do that, you monitor if somebody, you monitor a rise in PCO2 of 20 and see if they take a breath. Well, oxygenation and carbon dioxide level is kept completely stable on this machine and if we shut off the machine to rise the CO2, they're not getting any perfusion during that time and they die pretty much instantaneously when you shut off the machine. So this is a really difficult situation to assess. Also, we have many patients that have religious opposition to discontinuing life-sustaining technologies and this is extremely complicated when you have a patient that's put on this technology without consent and then you expect a family to decide whether we're going to shut the machine off. So overall, in my experience with this technology over the last six months, it's really clear that we're displacing the burden of decision-making from the physician to the family. It's really changing how people are dying in the emergency room. It's changing how people are dying in the operating room. Essentially, nobody dies in our cardiac ORs anymore. If there's a complication, they're placed on ECMO in an attempt to see if we can give them a transplant or if there can be a recovery of the intrinsic myocardium that's there and then it's put on the family to decide. It's no longer a physician decision in the operating room if it's okay. This burden is amplified when there's no bridging technology. What do you do when you have a patient that we think is going to get a transplant, has a tiny stroke, has difficulty swallowing and is no longer a transplant candidate and now they're on a completely supported device and it's the decision of him or her when they're completely awake on this machine to discontinue the therapy or we ask the family when's the correct time. It's also we're seeing an incredible amount of staff distress in our ICUs. As our ICUs are filling with these technologies, these are constant moral dilemmas with a lot of moral residue that's really resonating with the staff. So in looking at our cases, case number one is the successful use of this technology. A 55 year old that had an MI and had a cardiac arrest in our cath lab. He had urgent initiation of ECMO without consent, was on ECMO for five days but was a really great candidate for a total artificial heart, went through the surgery well and was able to be discharged home with a total artificial heart for two months. He then had a successful cardiac transplant and was discharged home. Case two is when technology kind of goes awry. We had a 68 year old orthodox Jewish female with severe mitral valve regurge due to radiation therapy. The preop clinic note mentions that there was a low risk of morbidity and mortality but when the patient got in, they cut out the old valve and due to extensive scarring couldn't get the new one in so she had no left-sided function. Was then unable to be weaned from bypass and taken out to the floor on ECMO. Day 10, she had severe biohemispheric ischemic strokes leaving the patient ineligible for transplant and they called me. Day 12, she had severe DIC, was bleeding, had further strokes and had minimal brain stem activity but we couldn't actually tell if she was brain dead. The family called their rabbi in New York City who strongly felt that withdrawing mechanical circulatory support was against Jewish law. Eight days go by with us trying to figure out if the patient is alive or dead on a machine and finally, there was enough clotting that the ECMO circuit failed and that's when the patient died. But this was an extreme burden that we placed on this family for eight days when there was really no medical options available. Case three was a 36 year old male with end stage renal disease on dialysis who had an unwitnessed arrest and ECMO was initiated without consent in our emergency department. He was cocaine and marijuana positive on admission and deemed almost immediately deemed ineligible for cardiac transplant due to drug abuse and lack of social support. No facility can take a total artificial heart or with dialysis. So he was looking at ECMO indefinitely in the cardiac ICU. So the family made the decision to withdraw mechanical circulatory support and the patient was awake and communicative when we shut off the machine and it's an instantaneous death when the circuit is clamped. So I wanna call for some areas that we need to do research. We're trying to develop a multi-center study to assess the current consent practice of cardiothoracic surgeons prior to high risk cardiac surgeries. If we're consenting family for the risk of death, are we also consenting them for the risk of coming onto a mechanical circulatory support system? We also need to do follow up with these families to determine the aspects of decision making which led to complex bereavement so that we can fix it as a physician community. We also need to develop clear protocols for withdrawing mechanical circulatory support so that the burden of how to do it and when to do it isn't placed on our staff but it's strictly a process that's followed. We also need a survey to assess the effect of mechanical circulatory support on staff burnout and do we need to be rotating people off of these cases so that they don't have to be doing it day and day and day. So I have a proposal for everyone here. Everybody that has a mechanical circulatory support program in their hospital. We need to establish screening tools to assess ECMO candidacy when they come into a cardiac ICU. What, do they have things that would preclude them from getting a transplant? Do they have things that would preclude them from even being a candidate for a total artificial heart? We need to create standards for post-implantation consent of the family to explain the risks and that this is a time limited therapy. We need increased education about mechanical circulatory support for all of us so that we know how to take care of these patients. We need to establish protocols for withdrawing mechanical circulatory support and I think we need triggers so that we have automatic involvement of clinical ethics and palliative care for support of both the patients and the medical teams. Thank you.