Extracorporeal membrane oxygenation in severe acute respiratory failure in postpartum woman with rheumatic mitral valve disease: benefit, factors furthering the success of this procedure, and review of the literature

Pregnancy is a common decompensation factor for women with post-rheumatic mitral disease. However, valvular heart diseases causing severe acute respiratory distress are rare. Use of extracorporeal membrane oxygenation (ECMO) early in the event of cardiorespiratory failure after cardiac surgery may be of benefit. Indeed, ECMO cardiopulmonary bypass (CPB) support could help pulmonary recovery if the mitral pathology is involved. A 31-year-old female patient at 30 weeks of amenorrhea was admitted to the obstetrics department with 40 degrees C hyperthermia and New York Heart Association (NYHA) class 4 dyspnea. The patient's medical history included a post-rheumatic mitral stenosis. Blood gases showed severe hypoxemia associated with hypocapnia. The patient needed to be rapidly intubated and was placed on ventilatory support because of acute respiratory failure. Transesophageal echocardiography showed a severe mitral stenosis, mild mitral insufficiency, and diminished left ventricular function, hypokinetic, dilated right ventricle, and a severe tricuspid regurgitation. An urgent cesarean section was performed. Because of the persistent hemodynamic instability, a mitral valvular replacement and tricuspid valve annuloplasty were performed. In view of the preoperative acute respiratory distress, we decided, at the beginning of the operation, to carry on circulatory support with oxygenation through an ECMO-type CPB at the end of the operation. This decision was totally justified by the unfeasible CPB weaning off. ECMO use led to an efficient hemodynamic state without inotropic drug support. The surgical post-operative course was uneventful. Early use of cardiorespiratory support with veno-arterial ECMO allows pulmonary and right heart recovery after cardiac surgery, thus avoiding the use of inotropic drugs and complex ventilatory support.     

体外膜式氧合支持治疗100例回顾性分析

目的 回顾性分析100例心肺功能衰竭患者应用体外膜式氧合(ECMO)支持治疗的临床经验.方法 2004年12月至2008年9月,对100例心肺功能衰竭患者行ECMO支持治疗.其中男性67例,女性33例;年龄5 d～76岁,平均(28±26)岁;体质量3.8～100.0 kg,平均(42±30)kg.采用全肝素涂抹技术的氧合器和离心泵ECMO系统,婴幼儿采用右心房-升主动脉插管,成人应用右心房-股动脉插管或股-动静脉插管,辅助期间流量40～220 ml·kg-1·min-1.结果 辅助时间12～504 h,平均(119±80)h.61例(61.0%)顺利撤离ECMO装置,ECMO平均时间(108±59)h;其中康复出院55例(90.2%),6例患者撤机后院内死亡.39例患者不能脱机或放弃治疗,ECMO平均时间(136±102)h.总出院率55.0%.存活患者ECMO前平均动脉压高于死亡患者(P=0.038);死亡患者ECMO前血乳酸水平高于存活患者(P=0.005).结论 ECMO支持是一种有效的循环呼吸衰竭辅助支持治疗方法,尽早对心肺衰竭患者使用ECMO支持治疗,避免重要脏器不可逆损伤,对提高治疗效果有积极的帮助.     

Extrakorporale Herz- und Lungenersatzverfahren

The use of extracorporeal support systems in cardiac and/or pulmonary failure is an established treatment option. Although scientific evidence is limited there is an increasing amount of data from individual studies, e.g. Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial 2010, suggesting that extracorporeal membrane oxygenation (ECMO) as a veno-venous pump-driven system is a life-saving procedure in severe respiratory failure. Initially established as a rescue option for postcardiotomy cardiac failure extracorporeal life support (ECLS) as a pump-driven veno-arterial cardiovascular support system is increasingly being used in cardiogenic shock after myocardial infarction, as bridging to transplantation or as part of extended cardiopulmonary resuscitation. The pumpless extracorporeal lung assist (pECLA) as an arterio-venous pumpless system is technically easier to handle but only ensures sufficient decarboxylation and not oxygenation. Therefore, this method is mainly applied in primarily hypercapnic respiratory failure to allow lung protective ventilation. Enormous technical improvements, e.g. extreme miniaturization of the extracorporeal assist devices must not obscure the fact that this therapeutic option represents an invasive procedure frequently associated with major complications. With this in mind a widespread use of this technology cannot be recommended and the use of extracorporeal systems should be restricted to centers with high levels of expertise and experience.     

Extracorporeal membrane oxygenation experience at the University of Pittsburgh

Between January, 1981, and May, 1985, 33 infants suffering from acute cardiorespiratory failure were treated with extracorporeal membrane oxygenation (ECMO) when all other forms of conventional management had failed. Only the patients with respiratory failure that was thought to be reversible were treated. Prolonged conventional respiratory management (more than five days) was considered a contraindication to ECMO support because of irreversible damage to the lungs caused by the barotrauma associated with conventional ventilation. Eighteen of the 33 patients (54%) survived and were discharged from the hospital. Patients with congenital diaphragmatic hernia had a high incidence of fatal bleeding complications (8 of 14). Good results were obtained in the newborns with persistent fetal circulation and meconium aspiration syndrome. We conclude that ECMO markedly improves the survival of newborns with severe respiratory failure who would have a mortality close to 100% with conventional respiratory management.     

Experience of heart transplantation from hemodynamically unstable brain-dead donors with extracorporeal support

Yang H‐Y, Lin C‐Y, Tsai Y‐T, Lee C‐Y, Tsai C‐S. Experience of heart transplantation from hemodynamically unstable brain‐dead donors with extracorporeal support. Abstract: The shortage of organ donors remains a major problem for transplantation worldwide. Potential donors after brain death may become hemodynamically unstable, despite maximal medical management, which ultimately leads to failure of organ procurement. We reviewed the medical records of five brain‐dead potential donors who presented with hemodynamic instability despite maximal medical management that were supported by extracorporeal circulation membrane oxygenation (ECMO). The outcomes of heart recipients were reviewed. The five donors under extracorporeal support finished a declaration of brain death without cardiac arrest. Donor organs, including three hearts, nine kidneys, and four livers, were harvested from the five donors under ECMO support. All three heart recipients recovered uneventfully after one yr of follow‐up. Our experience indicates that potential donors may experience central‐failure‐related hemodynamic instability after brain death, despite maximal medical support, which leads to a fatal result. Beyond medical management, prompt and early extracorporeal support for salvaging brain‐dead potential donors from cardiac death seems to be a practical strategy to increase the donor pool and preserve donor organs.     

Bloodless extracorporeal membrane oxygenation in the Jehovah's Witness patient

The successful use of prolonged extracorporeal life support with a heart-lung machine was first performed in 1972, as described by Hill et al., on a young man with post-traumatic respiratory failure. The first successful use of extracorporeal membrane oxygenation (ECMO) was 1976 by Bartlett et al. Since this time, the use of ECMO for neonatal and pediatric pulmonary support has become a standard of care in many children's hospitals. The use of ECMO, being a very invasive procedure, is not without risk. In our experience, most patients require multiple transfusions of the different blood components (packed red blood cells, plasma, platelets, and cryoprecipitate). Exposure to one or more blood products often occurs with connection to the ECMO circuit, as the circuit is generally primed with blood products or whole blood. Jehovah's Witnesses (JWs) are known best in the medical community for their refusal of blood products, even at the risk of death, which presents challenges for health care providers. This belief stems from the biblical passages that have been quoted as forbidding transfusion: Genesis 9:3-4, Leviticus 17:13-14, and Acts 15:19-21. This refusal of blood poses even greater challenges when treating the pediatric JW population. When a blood product is deemed medically necessary for the JW patient, the healthcare provider must either seek legal intervention, or support the patient's/family's wishes and associated outcome. This ethical dilemma may be further complicated in the setting of therapies, which may pose additional risks and potentially less clear benefit such as with ECMO. Bloodless cardiac surgery with cardiopulmonary bypass has been reported in the JW population in adults and pediatrics, including neonates. After a thorough search of the literature, no published report of a JW patient being supported on ECMO without blood or blood component utilization was identified. This case report will present our experience with multiple day, bloodless ECMO support of a 17-year-old male patient of the JW faith.     

Extracorporeal Membrane Oxygenation as a Bridge to Organ Donation: A Case Report

Hemodynamic instability is a frequent complication in potential organ donors. Despite maximal medical therapy, it can lead to cardiac arrest with consequent loss of organs. In this study we present the use of extracorporeal membrane oxygenation circulation (ECMO) as a bridge to organ procurement in a potential donor with hemodynamic instability. A 14-year-old girl who drowned in a pool experienced cardiorespiratory arrest with prolonged resuscitation. In the intensive care unit (ICU), she displayed hemodynamic instability requiring high doses of inotropis agents. After 60 hours for ICU admission clinical diagnosis of brain death, was established and consent for organ donation obtained. During the observation period, the hemodynamic instability worsened, requiring ECMO which was continued during transport to the operating room and during organ retrieval, totaling 3 hours. We retrieved liver, kidneys, heart valves and cornea. Liver and kidney transplantations were successfully performed in 3 recipients, all of whom displayed appropriate organ functions after 15 months. In conclusion, ECMO support of potential donors can be used to prevent cardiac arrest, preserve organs, and thus increase the number of potential donors.     

Ambulatory venovenous extracorporeal respiratory support as a bridge for cystic fibrosis patients to emergent lung transplantation

Venovenous extracorporeal membrane oxygenation (VV ECMO) is a therapeutic option to bridge patients with advanced lung disease to lung transplantation. The use of VV ECMO avoids the use of mechanical ventilation while allowing patients to participate in physical therapy and to eat normally while receiving respiratory support. We describe the successful use of ambulatory single-venous VV ECMO as a bridge to bilateral lung transplantation in 4 patients with end-stage lung disease due to cystic fibrosis who developed acute hypercapnic respiratory failure. The use of ambulatory single-venous VV ECMO was safe and effective in this small cohort of CF patients. Based on our experiences, our belief is that a key step in the treatment course was early application of VV ECMO soon after development of acute respiratory failure requiring mechanical ventilation.     

Emergency Use of Extracorporeal Membrane Oxygenation in Cardiopulmonary Failure

Severe pulmonary and cardiopulmonary failure resistant to critical care treatment leads to hypoxemia and hypoxia-dependent organ failure. New treatment options for cardiopulmonary failure are necessary even for patients in outlying medical facilities. If these patients are in need of specialized center treatment, additional emergency medical service has to be carried out quick and safely. We describe our experiences with a pumpless extracorporeal lung assist (PECLA/iLA) for out-of-center emergency treatment of hypercapnic respiratory failure and the use of a newly developed hand-held extracorporeal membrane oxygenation (ECMO) system in cardiac, pulmonary, and cardiopulmonary failure (EMERGENCY-LIFE Support System, ELS System, MAQUET Cardiopulmonary AG, Hechingen, Germany). Between March 2000 and April 2009, we used the PECLA System (n = 20) and the ELS System (n = 33) in adult patients. Cannulation was employed using percutaneous vessel access. The new hand-held ELS System consists of a centrifugal pump and a membrane oxygenator, both mounted on a special holder system for storing on a standard patient gurney for air or ground ambulance transfer. Bedside cannulation processes were uneventful. The PECLA System resulted in sufficient CO₂ removal. In all ECMO patients, oxygen delivery and systemic blood flow could be restored and vasopressor support was markedly down. Hospital survival rate in the PECLA group was 50%, and 61% in the ECMO group. Out-of-center emergency treatment of hypercapnic pulmonary failure with pumpless extracorporeal gas exchange and treatment of cardiac, pulmonary, and cardiopulmonary failure with this new hand-held ECMO device is safe and highlyeffective. Patient outcome in cardiopulmonary organ failure could be improved.     

Extrakorporale Membranoxygenierung

Altough the concept of extracorporeal membrane oxygenation (ECMO) therapy has been established and used for over 30 years, in recent years the number of implanted ECMO systems has increased and it has developed into an integral component of the clinical routine. All forms of ECMO therapy can be summarized under the term extracorporeal life support (ECLS). The latest developments are surface-coated and miniaturized ECMO systems which allow the long-term support of critically ill patients. Severe lung failure with a normal cardiac index is treated by venovenous ECMO (vv-ECMO). The interventional lung assist/pumpless extracorporeal lung assist (iLA/PECLA) systems are mostly indicated for hypercapnic respiratory acidosis as is frequent with acute respiratory distress syndrome (ARDS). The support of ARDS patients with ECMO seems to improve outcome by allowing further protective lung ventilation. Cardiopulmonary failure is treated by venoarterial ECMO (va-ECMO) and is often used in an interdisciplinary setting in emergency rooms where survival of these patients is increased by up to 40%. Although clear indications are defined only a few risk analyses have been carried to show which patients benefit most from va-ECMO. The decision whether to implant a va-ECMO or not is still based on center and physician experience. To guarantee safe and high quality treatment for patients interdisciplinary ECMO therapy has to be regulated in the near future. New concepts for ECMO therapy, e.g. the total artificial lung concept or the long-term treatment of patients with pulmonary hypertension with ECMO need further clinical observation and testing.     

Erstellung einer S3-Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“

In Germany, the ever-increasing use of mechanical extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed over the last few years. In 2015, more than 2,800 ECLS/ECMO implantations were carried out in Germany. Despite this widespread use of the systems, the only national and international guidelines that are available are those in which the use of ECMO/ECLS is described as just one aspect of complex treatment cascades for various illnesses. Against this background it appears necessary to draft evidence-based recommendations on the complex management of patients who need and receive ECMO/ECLS treatment, in which staff-related, procedural and infrastructural requirements are defined.Therefore, in July 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered an S3 guideline with the Association of Scientific Medical Societies in Germany (AWMF).The aim of this interdisciplinary and multiprofessional guideline is to provide substantiated recommendations on the use of extracorporeal procedures (extracorporeal life support/extracorporeal membrane oxygenation) in cases of cardiac, circulatory, and cardiopulmonary failure.With the aim of drawing up a methodically high-quality guideline, the project management was designed according to the internationally accepted quality criteria for guidelines, “The Appraisal of Guidelines for Research and Evaluation” (AGREE) and the Germany Guideline Evaluation Instrument (DELBI).     

Extracorporeal membrane oxygenation for newborn respiratory failure

Respiratory failure is the leading cause of death in the newborn. Conventional therapy is very successful with 80% of infants weaned from ventilatory support. For neonates with severe respiratory failure, unresponsive to maximal medical therapy, extracorporeal membrane oxygenation (ECMO) offers an alternative means of management. Venoarterial bypass is achieved by cannulating the right atrium via the internal jugular vein and the aortic arch via the right common carotid artery. A 5-inch roller pump is used to circulate the blood through a 0.4 or 0.8 m2 silicone membrane lung. Management includes heparinization, intravenous alimentation, antibiotic coverage, and reduction of FiO2 and airway pressure. Thirty infants aged 12 to 186 hours were placed on ECMO. Each met strict criteria designed to predict greater than 90% mortality. Time on bypass ranged from 37 to 250 hours. Success, defined by weaning from ECMO and ventilatory support, was achieved in 23. Twenty-one remain alive; 18 have excellent outcome with normal growth and development although follow-up is short (1 to 19 mos). These results corroborate reports from the pioneers of the technique and further support the use of ECMO for neonates with respiratory failure unresponsive to conventional therapy.     

Institution of extracorporeal membrane oxygenation late after lung transplantation – a futile exercise?

The use of and indications for extracorporeal membrane oxygenation (ECMO) are expanding as its reliability improves with widely varying results reported. A retrospective review of 24 lung transplant recipients who required ECMO support postoperatively was performed with 13 patients requiring ECMO within the first 48 h ("early" group) and 11 requiring ECMO after seven d postoperatively ("late" group). The majority of early ECMO group had primary graft failure patients and the late ECMO group comprised patients with infection or non-specific graft failure. There were significant differences in outcomes between groups, with 10/13 in the early group and 4/11 in the late group successfully weaned from ECMO (p = 0.045). Six of the 13 patients in the early group and none of the late group survived to hospital discharge (p = 0.009). The late ECMO group had a much higher incidence of death owing to complications existing prior to institution of ECMO (essentially uncontrolled infection or organ failure). There were no differences in complications arising during ECMO between groups. Late institution of ECMO in lung transplant recipients for causes other than primary graft failure is associated with such poor survival that its use should be considered only in very select cases.     

Extracorporeal life support for posttraumatic acute respiratory distress syndrome at a children's medical center

Background: Primary traumatic injury was considered previously a contraindication for institution of extracorporeal life support because of high risk for persistent or new bleeding. Published experience in adults suggests that extracorporeal membrane oxygenation (ECMO) can successfully support trauma victims with pulmonary failure. The authors reviewed their experience with the use of ECMO in pediatric and adult trauma patients with acute respiratory distress syndrome (ARDS) at a children’s medical center.Methods: ECMO Center records from 1991 through 2001 (76 children, 8 adults) were reviewed to identify all patients with a primary or secondary ICD-9 diagnostic code of posttraumatic ARDS in addition to documented trauma.Results: Five children and 3 adults with traumatic injury and ARDS received ECMO support. Seven patients were injured in motor vehicle collisions; one patient suffered a gunshot wound to the chest. Patient ages ranged from 21 months to 29 years (pediatric median, 4 years; range, 21 months to 18 years). Four patients had pre-ECMO laparotomies, including 3 who required splenectomy. Four patients had liver lacerations, 3 had pulmonary contusions, and 1 had a renal contusion. Median ventilation before ECMO was 6 days (range, 2 to 10). Seven of 8 patients were placed on venovenous (VV) ECMO. Seven patients had significant bleeding on ECMO. Patients were treated with blood product replacement, epsilon-aminocaproic acid (EACA), and aprotinin infusions. Surgical intervention was not required for bleeding. Six patients received hemofiltration. Median time on ECMO was 653 hours (range, 190 to 921 hours). Six of 8 patients overall survived (75%). Four of 5 pediatric patients survived.Conclusions: Children and adults with severe posttraumatic ARDS can be treated successfully on VV extracorporeal support. Hemorrhage occurs frequently but is manageable.     

Recent progress and future prospect of the prolonged extracorporeal lung assist for respiratory failure

Extracorporeal membrane oxygenation (ECMO) is becoming an accepted therapeutic option for acute respiratory failure in both infants and adults. ECMO has been applied for relatively short-term support and numerous centers have reported satisfactory results with emphasis on patient selection, techniques of cannulation and perfusion, and prevention of complications. To use ECMO for a prolonged support, however, new type of artificial lung and system need to be developed. Most of the membrane oxygenators have the possibility of serum leakage through micropores. To prevent this problem, several dense membrane oxygenators have been developed and clinically used with good gas exchange. A low heparin dosage during ECMO results in reduced bleeding complication. Full systemic heparinization can be avoided during ECMO by using heparin-coated perfusion equipment. Respiratory support by means of pumpless PA-LA extracorporeal membrane oxygenation driven by pulmonary arterial pressure is attractive because of its simplicity and might be suitable for prolonged use. Further studies are necessary to develop an oxygenator for long-term ECMO.     

Institutional experience with extracorporeal membrane oxygenation in lung transplantation.

Background: Extracorporeal membrane oxygenation (ECMO) is currently accepted in lung transplantation either to bridge patients to transplantation or to treat postoperatively arising severe primary graft failure. Based on promising initial experiences we have since 2001 implemented ECMO as the standard of intraoperative extracorporeal support in lung transplantation (LuTX) patients with haemodynamic or respiratory instability with the potential to prolong ECMO support into the perioperative period. The aim of this paper is to summarise our total experience with the use of ECMO in LuTX. Methods: We retrospectively reviewed all 306 patients undergoing primary lung transplantation from 1/2001 to 1/2006 with regard to the different forms of ECMO use. Results of all patients requiring ECMO were compared to those without ECMO during the observation period. Results: ECMO was used in 147 patients in total. Two patients were bridged to transplantation. A total of 130 patients received intraoperative ECMO support. In 51 of these patients ECMO was prolonged into the perioperative period. Five of these patients required ECMO support again in the postoperative period due to graft dysfunction. Contrary cardiopulmonary bypass was used in 27 patients mainly with concomitant cardiac defects. Eleven of these patients needed therapeutic ECMO in the further course. A total of 149 patients without relevant risk factors were transplanted without any intraoperative extracorporeal support. Six of these patients required ECMO support in the postoperative period for treatment of primary graft dysfunction. Overall 3-month, 1-year and 3-year survival rates were 88.6%, 82.1% and 74.63%. The mentioned survival rates were 85.4%, 74.2% and 67.6% in the intraoperative+/-prolonged ECMO group; 93.5%, 91.9% and 86.5% in the no support group and 74.0%, 65.9% and 57.7% in the CPB group. Conclusion: ECMO is a valuable tool in lung transplantation providing the potential to bridge patients to transplantation, to replace CPB with at least equal results and to overcome severe postoperative complications. Favourable survival rates can be achieved despite the fact that ECMO is used in the more complex patient population undergoing lung transplantation as well as to overcome already established severe complications.     

Successful Extracorporeal Membrane Oxygenation for Right Heart Failure After Heart Transplantation—2 Case Reports and Literature Review

After heart transplantation (HT), transient right heart failure (RHF) is common. If it does not improve with appropriate medical therapy, we must consider mechanical support. Recently, extracorporeal membrane oxygenation (ECMO) has shown better results than a right ventricular assist device or retransplantation. Two HT patients with hypertrophic cardiomyopathy had cold ischemic times beyond >240 minutes. After HT, their right heart function worsened and was unresponsive to medical therapy. After our application of ECMO, weaning was successful and the patients were discharged without complication. Early application of ECMO for RHF after HT is a good option.     

Extracorporeal membrane oxygenation for postcardiotomy mechanical cardiovascular support in children with congenital heart disease

Extracorporeal membrane oxygenation (ECMO) is increasingly used to support postcardiotomy cardiorespiratory failure in children with congenital heart disease. We report on survival outcomes and factors associated with survival for postcardiotomy ECMO patients.     

Resuscitation of fat embolism syndrome with extracorporeal membrane oxygenation

Embolization of marrow fat appears to be an inevitable consequence of long bone fractures. Pulmonary fat embolism (FE) with cardiovascular collapse is associated with a high mortality rate because of acute right ventricular failure and hypoxia. Immediate and appropriate resuscitation is required to prevent sudden death. Although extracorporeal membrane oxygenation (ECMO) has been used for a multitude of applications involving respiratory and circulatory collapse, its full potential as a standard conventional therapy has yet to be exploited. Herein, we describe the successful use of veno-venous (V-V) ECMO in a trauma patient who initially presented with fractures of the right ulna and femur. After surgery, the patient rapidly decompensated despite massive ventilatory support and was placed on ECMO. ECMO support lasted approximately 120 hours followed by an uneventful recovery and discharge 10 days later.     

Successful gastrorrhaphy on ECMO

From April 1985 to November 1987, over 100 infants were evaluated for extracorporeal membrane oxygenation (ECMO) in the treatment of respiratory failure. Of these infants, 40 underwent ECMO after failure of conventional treatment. Four developed gastroduodenal perforations. One developed a perforation prior to going on ECMO and died after several hours on ECMO, one developed a perforation while being treated conservatively for respiratory failure that never required ECMO, and two developed perforations requiring laparotomy while on ECMO. These two infants constitute the first report of successful gastrorrhaphy in infants while being supported by ECMO and anticoagulation with heparin. Particular measures helpful in the management of these infants included near-total cardiopulmonary bypass, reduction of the activated clotting time to 170 to 200, transverse abdominal incision for exposure, use of electrocautery, appropriate drainage of the operative site, insertion of a gastrostomy for gastric decompression and irrigation, rapid weaning from ECMO as soon as respiratory support could be provided by conventional methods, and the use of massive blood and platelet transfusions. In summary, 33 of 40 infants undergoing ECMO survived. Furthermore, two of the three infants with intestinal perforation who underwent ECMO have survived without significant short-term sequelae, and are 24 and 30 months of age, respectively. Therefore, we believe that despite severe respiratory failure requiring ECMO and anticoagulation with heparin, infants with intestinal perforation can be managed surgically with anticipated survival and good long-term prognosis.