ECMO introduction for CVS

ECMO
extracorporeal membrane oxygenation ECMO
(Extracorporeal Life Support) ECLS

ECMO

prolonged partial cardiopulmonary bypass

ECMO

prolonged partial cardiopulmonary bypass

Up to several weeks

ECMO

prolonged partial cardiopulmonary bypass

The patients heart & lungs must work.

ECMO vs CPB
Venous reservoir

CPB

CPB vs ECMO
CPB Site Heparin (ACT) Autotransfusion Hypothermia Hemolysis Hemodilution Arterial filter OR >600 Yes Yes Yes Yes Yes Venous reservoir Yes ECMO ICU No 160-220 No No No No No

ECMO
Short-term cardiopulmonary support Buy time to decide the next step
Recovery Transplantation long-term device (ventricular assist device) Operation (CABG, pulmonary embolectomy,..) Give-up

for lung
1. support : O2 supply & CO2 removal
2. rest : reduce ventilator induced lung injury

for heart
support : improve systemic perfusion
rest :
catecholamine
myocardial work

decrease preload requirement and congestion

ECMO Mode
VV - ECMO VA - ECMO

VV-ECMO
indication : for lung disease only purpose : to decrease barotrauma
( to prevent ventilator-induced lung injury)

ventilator setting :
PC mode, PEEP >10 , PIP < 30 VR --> PaCO2, FiO2--> PaO2

VA-ECMO
advantage :
1. both lung & heart support 2. higher PaO2
For hemodynamic support

ECMO type
Centrifugal pump + hollow fiber oxygenator
Advantages: rapid priming, heparin binding Disadvantages: plasma leak, pump thrombosis

ECMO type
Centrifugal pump + hollow fiber oxygenator
Advantages: rapid priming, heparin binding Disadvantages: plasma leak, pump thrombosis

Roller pump + silicone membrane oxygenator

Advantages: prolonged use, less hemolysis (?) Disadvantages: difficult priming, no heparin binding

ECMO choice for a patient

Emergency? centrifugal Duration? roller Bleeding risk? centrifugal Transport ? centrifugal

ECMO is mainly for neonatal respiratory diseases. (45.9%)

Surfactant therapy NO inhalation High frequency oscillatory ventilation Prone positioning General critical care ECMO for neonatal lung diseases is decreasing.

ECMO in NTUH ( 1994 Aug. 11 2013 Dec. 31 )

Neonatal lung disease ARDS Lung THx Pulmonary embolism Neurosurgery NHBD Others 1711 298121 5533 2813 4 3 26 2013 MCS Post-cardiotomy Acute myocarditis Cardiomyopathy AMI CHD Septic shock 1517 481148 12580 20371 30197 6322 11610

PH and RV failure
Acute rejection Others of MCS

329
338 16355

TOTAL : 1965

ECMO for adult ARDS

H1N1

Why there is ECMO at NTUH ?

NTUH Heart Transplantation

45 40 35 30 25 20 15 10 5 0 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

What happened in 1995?

 Try to increase heart transplantation number! Our advantage? strategy vs tactics

If a low cardiac output patient come to our hospital, what can we do ? A complete heart failure treatment program

Treatment of low cardiac output

Drug digoxin, diuretics, ACEI, ARB, aldosterone antagonist Carvedilol, metoprolol, bisoprolol milrinone dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol PGE1 NO inhalation Mechanical circulatory support IABP VAD (Heartmate, Thortec, biopump, roller pump, others) ECMO Surgery Batista operation, SVR heart transplantation (orthotopic, heterotopic) heart-lung transplantation

Treatment of low cardiac output

Drug digoxin, diuretics, ACEI, ARB, aldosterone antagonist Carvedilol, metoprolol, bisoprolol milrinone dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol PGE1 NO inhalation Mechanical circulatory support IABP VAD (Heartmate, Thortec, biopump, roller pump, others) ECMO Surgery Batista operation, SVR heart transplantation (orthotopic, heterotopic) heart-lung transplantation

Case Demonstration

ECMO
mechanical circulatory support
VA-ECMO

 A good condition before HTx This can guarantee a good result !

In the past?

HTx

VAD

ECMO

Mechanical circulatory support

Heart failure: Medical treatment MCS
IABP (intra-aortic balloon pump) ECMO (extracorporeal membrane oxygenation) VAD (ventricular assist device) TAH (total artificial heart)

IABP
Because of its relative non-invasiveness, The first choice of MCS But, disadvantages:
Small BW RV failure Tachyarrhythmia CPR AR Aortic aneurysm Atherosclerosis etc (KTx) Limited cardiac support ( ~1 L/min)

VAD
disadvantage :
1. thoracotomy: time delay, general anesthesia, transport to OR, OP risk 2. technique demanding 3. RV failure in LVAD LV failure in RVAD too complex in BVAD 4. Bleeding 5. Pediatric sized device for children (?)

Ventricular Assist Device (VAD)

Only in stable patients with anticipated long-term use Not for critical patients with unsure diagnosis

ECMO
advantage :
1. Rapid priming, bedside, local anesthesia, easy, quick, safe (ECPR) 2. Much cheaper than VAD 3. support for RV, LV, lung (safe in unknown conditions) 4. Carmeda Bioactive Surface (BAS) 5. for both adults and children 6. neck, femoral, thoracic

ECMO
advantage :
1. Rapid priming, bedside, local anesthesia, easy, quick, safe (ECPR) 2. Much cheaper than VAD 3. support for RV, LV, lung (safe in unknown conditions) 4. Carmeda Bioactive Surface (BAS) 5. for both adults and children 6. neck, femoral, thoracic

flexible

ECMO
mode
V-A V-V VV-A VV-V V-VA A-V

site
Neck Axillar Thoracic Femoral

oxygenator
Medtronic Medos Jostra silicone

pump
Centrifugal roller

Very flexible

HTx

VAD

ECMO

Different patients different situations

different treatments

2005 Jan. 5 Press conference at NTUH

11 y/r, boy, HTX after 18 days of ECMO support

ECMO --- > VAD --- > HTx

Treatment of low cardiac output

Drug digoxin, diuretics, ACEI, ARB, aldosterone antagonist Carvedilol, metoprolol, bisoprolol milrinone dopamine, dobutamine, epinephrine, norepinephrine, isoproternenol PGE1 NO Mechanical circulatory support IABP A part, but important part of the whole system. ECMO VAD (Heartmate, Thortec, biopump, roller pump) Surgery Batista operation, SVR heart transplantation (orthotopic, heterotopic) heart-lung transplantation

ECMO
respiratory support for ARDS VV-ECMO

An Example
A 33-yr-old, male Flame burn
20% TBSA 2nd burn 2.5% TBSA 3rd burn Inhalation injury

Vicious cycle in ARDS

personal experience

ARDS
hypercarbia Vs hypoxemia
1. permissive hypercarbia 2. do not overventilate to improve ABG 3. treat ARDS with ECMO earlier

Result
survivors Sex (M/F) age PaO2/FiO2 PEEP 4/3 31.7+13.5 66 12 Non-survivors 11/6 41.4+22.1 54 12

ARDS score
ATN Patient source Burn CVS GS Med NS

3.6
1/7 2 2 1 1 1

3.6
10/17 2 2 8 4 1

ECMO for ARDS

1/3 successful rate, why ?
1. ARDS vs MOF 2. time competition a. slow recovery of ARDS b. complication of long-term ECMO

Indications of ECMO in the near future

As a mechanical circulatory support:
Post-cardiotomy cardiogenic shock Double bridge (ECMO VAD HTx) Acute myocarditis AMI cardiogenic shock (ECPR) Shock due to heart stunning Lung transplantation Heart-lung support during the operation Non-heart-beating-donor support Rescue for acute pulmonary embolism Airway surgery, airway trauma hypothermia

Replace CPB:

Ventilatory support
Asthma ARDS Neonatal pulmonary diseases

ECMO in NTUH ( 1994 Aug. 11 2009 Dec. 31 )

Neonatal lung disease ARDS Lung THx Pulmonary embolism Neurosurgery NHBD Others 2 179 ( 73 ) 50 19 ( 8 ) 4 26 13 ( 6 )

MCS
Post-cardiotomy Acute myocarditis Cardiomyopathy AMI CHD Septic shock PH and RV failure

990
379 ( 115 ) 78 ( 45 ) 119 ( 45 ) 194 ( 50 ) 25 ( 6 ) 66 ( 8 ) 17 ( 2 )

Acute rejection
Others of MCS

17 ( 2 )
98 ( 29 )

TOTAL : 1283

( ) survival

Why ECMO succeeds in NTUH?

Why ECMO succeeds in NTUH ?

1. NTUH
2000 beds, national hospital, 114 years Totem of Taiwan society Critical mass A good background

SICU Technician
24 hr /day 365 day/ year

366 days / leap year

Core team
A core team A large team A society

Because we can dream, we become human being! History is created by few people. How to recruit a core team? Selection? Training? Select trainable people.

Why ECMO succeeds in NTUH ?

1. NTUH
2000 beds, national hospital

2. extended indications enough cases

(>100 cases/year)

Economic scale

Indications of ECMO in the near future

As a mechanical circulatory support:
Post-cardiotomy cardiogenic shock Double bridge (ECMO VAD HTx) Acute myocarditis AMI cardiogenic shock (ECPR) Shock due to heart stunning Lung transplantation Heart-lung support during the operation Non-heart-beating-donor support Rescue for acute pulmonary embolism Airway surgery, airway trauma hypothermia

Replace CPB:

Ventilatory support
Asthma ARDS Neonatal pulmonary diseases

Why ECMO succeeds in NTUH ?

1. NTUH
2000 beds, national hospital,

2. extended indications enough cases

(>100 cases/year)

3. excellent SICU background

ECMO is a high technology treatment

 A locomotive engine Vs a whole train Skyscraper Vs modern city

One more step forwards But reasonable enough

Why ECMO succeeds in NTUH ?

1. NTUH
2000 beds, national hospital,

2. extended indications enough cases

(>100 cases/year)

3. excellent SICU background

ECMO is a high technology treatment

4. team work
CVS, ICU, nurse, technician

Why ECMO succeeds in NTUH ?

1. NTUH
2000 beds, national hospital,

2. extended indications enough cases

(>100 cases/year)

3. excellent SICU background

ECMO is a high technology treatment

4. team work
CVS, ICU, nurse, technician, bypass ?

5. training program & protocol

Protocol, protocol, protocol

http://www.sicu.org

Why ECMO succeeds in NTUH ?

1. NTUH
2000 beds, national hospital,

2. extended indications enough cases

(>100 cases/year)

3. excellent SICU background

ECMO is a high technology treatment

4. team work
CVS, ICU, nurse, technician, bypass ?

5. training program & protocol

Protocol, protocol, protocol

6. continuous revision
Long term development

Case record M & M conference for every case RCA (root cause analysis) Continuously Revise system (0.9 theory)

Why ECMO succeeds in NTUH?

Strong background A core team (select trainable team member)
responsible

Economic scale Team work SOP (mass production) Work hard and smart

All you need to set up ECMO Put everything on the wheel Then,
OR, ICU, cath room, ES, ward, etc

ECMO cart

Taipei city/Taipei county area = 12

ECMO success need :

1. underlying problem soon reversible 2. no severe 2nd organ damage 3. no complication from ECMO use

ECMO success need :

1. case selection (treat pt. , not Dr.) 2. early use 3. intensive ECMO care

Indications of ECMO in the near future

As a mechanical circulatory support:
Post-cardiotomy cardiogenic shock Double bridge (ECMO VAD HTx) Acute myocarditis AMI cardiogenic shock (ECPR) Shock due to heart stunning Lung transplantation Heart-lung support during the operation Non-heart-beating-donor support Rescue for acute pulmonary embolism Airway surgery, airway trauma hypothermia

Replace CPB:

Ventilatory support
Asthma ARDS Neonatal pulmonary diseases

AMI with cardiogenic shock

60 y/r, male, chest tightness ES, sudden VT/Vf, DC shock, now, BP:80/50 under dopamine 20 mcg/kg/min 60 y/r, male, stable angina, frequency , cath PTCA, LAD dissection, BP, HR IABP, BP: 80/50 AMI, refractory VT/Vf, DC shock 40 times
AMI & CS ECMO Cath off pump CABG ICU support

ECMO rescue for AMI with CS

Pre-cath:
to stabilize the patients

During cath & revascularization

to support the patients for procedure

After revascularization
To support hemodynamics until heart recovery

Post-CABG VT/Vf J Formos Med Assoc 2002:101:283-286

A dancer
A modern medical miracle

ECMO
Strategy weapon Front-line weapon
A necessity in a medical center