Prolonged extracorporeal membrane oxygenation and circulatory support as bridge to lung transplant

A 38-year-old man with progressive alveolitis secondary to polymyositis was treated for 52 days with venovenous and venoarterial extracorporeal membrane oxygenation as a bridge to bilateral lung transplantation. The patient survived, despite multiple complications, and is now back home with good pulmonary function. He is working part-time nearly 3 years post-transplant. This case shows that long-term extracorporeal lung assist is a viable but demanding alternative for bridging patients to pulmonary transplantation. This case also shows that right ventricular failure necessating conversion to veno-arterial assist does not necessarily predict right ventricular failure post-transplant.     

Temporary fenestration using venoatrial extracorporeal membrane oxygenation after the Fontan operation

A 28.7-month-old male child who had undergone a Norwood operation and bidirectional cavopulmonary shunt at the age of 5 days and 6.6 months, respectively, underwent the extracardiac conduit Fontan operation. After the operation, high-volume resuscitation was needed, which led to high central venous pressure (CVP) and low arterial oxygen saturation. Venoatrial extracorporeal membrane oxygenation (ECMO) was initiated between the superior vena cava and the right atrium with one third of the expected normal cardiac output. This low-flow venoatrial ECMO immediately terminated the vicious cycle caused by high venous pressure in the Fontan circulation. He was weaned from ECMO and discharged home.     

Resuscitation and circulatory support using extracorporeal membrane oxygenation for fulminant pulmonary embolism

Fulminant pulmonary embolism (PE) with circulatory collapse is associated with a high mortality rate due to acute right ventricular failure and hypoxia. Immediate and appropriate resuscitation and circulatory support in the perioperative period is mandatory to prevent sudden death. Extracorporeal membrane oxygenation (ECMO) was recently introduced for extracorporeal life support in patients with circulatory collapse and has provided an excellent outcome. We report on the effectiveness of ECMO support for fulminant PE. Seven patients were placed on veno-arterial ECMO for circulatory collapse caused by fulminant PE refractory to conventional treatment. After resuscitation, all patients underwent pulmonary angiography, and thrombolytic therapy was administered in all 7 patients under ECMO support. Three patients who did not improve by thrombolysis underwent embolectomy with standard cardiopulmonary bypass. Two thrombolysis and 2 surgery patients were weaned from bypass and survived. The duration of support ranged from 18-168 h (mean = 67.8 +/- 67.1 h), with maximum bypass flow rates of 2.0-4.5 (mean = 3.5 +/- 0.9). There were no device-related complications during support. In total, 4 patients (57%) were successfully weaned from support and discharged from the hospital in good condition. All patients who survived required prolonged support (27, 82, 151, and 168 h). We conclude that resuscitation and circulatory support using ECMO can be effective, life-saving measures in cases of circulatory collapse caused by fulminant PE.     

Mechanical circulatory support for infants and children with cardiac disease

Mechanical circulatory support is assuming an expanding role in the practice of congenital cardiac surgery. Extracorporeal membrane oxygenation and centrifugal ventricular assist devices are still the mainstay of mechanical circulatory support for children; however, newly developed pulsatile, paracorporeal ventricular assist devices designed for pediatric applications are achieving increased utilization. In addition, several new, continuous flow devices that are under development as fully implantable systems for adults, ultimately may be useful for pediatric patients.     

Phosphorylcholine or heparin coating for pediatric extracorporeal circulation causes similar biologic effects in neonates and infants

OBJECTIVE: Cardiac surgery for complex congenital malformations with use of extracorporeal circulation predisposes to an excessive systemic inflammatory response and a consecutive capillary leak syndrome. In a prospective randomized study the influence of 2 oxygenators especially designed for pediatric use on inflammatory markers and clinical outcome was investigated. METHODS: Forty neonates and infants (body surface area, <0.36 m(2)) undergoing cardiac surgery with extracorporeal circulation were randomized into one of 3 groups: in the first group (n = 14) the Medtronic Minimax Oxygenator and in the second group (n = 12) the Dideco Lilliput 1 Oxygenator, both with a 750-mL priming volume, were used. In the third group the Dideco Lilliput 1 Oxygenator was filled with a reduced priming volume of 450 mL. Parameters of interest for evaluation of a systemic inflammatory response after extracorporeal circulation were interleukin 6, tumor necrosis factor alpha, neutrophil elastase, complement C3, and free hemoglobin. In addition, erythrocyte, leukocyte, and thrombocyte counts and hemoglobin and C-reactive protein values were determined at different measurement points before, during, and after the operation. RESULTS: In all 3 groups peak values for tumor necrosis factor alpha were observed during the operation, whereas interleukin 6, elastase, and free hemoglobin values peaked in the first 4 hours. The highest values for leukocytes and C-reactive protein were obtained between 24 and 72 hours after the operation. Erythrocyte and thrombocyte counts, as well as hemoglobin values, were lowest at extracorporeal circulation onset, normalizing under substitution in the first 4 hours after the operation. By using the Lilliput/750 oxygenator, higher interleukin 6 values 1 and 4 hours after the operation and higher tumor necrosis factor alpha values during and 1 hour after the operation could be observed compared with results with the Minimax and Lilliput/450 oxygenators. In spite of our randomization protocol, patients in the Lilliput/750 group were significantly smaller and younger than those in the Minimax group. However, the statistical analysis showed no correlation between age and interleukin 6 or tumor necrosis factor alpha values, but it did show a correlation between younger age and the occurrence of capillary leak syndrome. Accordingly, the number of children with clinically complicated course (capillary leak, longer duration of catecholamine therapy, and ventilation) was higher in the Lilliput/750 group than in the Minimax group. CONCLUSION: By using an adequate priming volume, the systemic inflammatory response is similar after use of the Dideco Lilliput 1 Oxygenator and the Medtronic Minimax Oxygenator. Tip-to-tip surface coating of the extracorporeal circulation with either heparin or phosphorylcholine seems to have similar biologic effects in neonates and infants undergoing cardiac surgery.     

体外膜肺氧合治疗患者早期活动临床实践

对10例体外膜肺氧合治疗患者开展早期活动,包括组建体外膜肺氧合患者早期活动团队,早期活动评估及活动计划的制订与实施等。结果10例患者体外膜肺氧合治疗后(4.60±1.26)h可定时被动翻身,摆放功能体位;(14.00±6.91)d患者意识清醒,可完成0～3级水平的活动,每天主动活动时间(33.89±11.67)min。活动期间未发生不良事件。体外膜肺氧合支持14～69 d后10例患者均顺利脱离体外膜肺氧合,转普通病房进一步治疗。