“becmo”: if you build it, we will pump case report using a berlin heart with an ecmo oxygenator...

“bECMO”: If You Build It, We Will PumpCase report using a Berlin Heart with an ECMO

Oxygenator

Jerri Hilshorst CCP, Aimee Gardner CCP, John Lombardi CCP, Robert Ferguson CCP, Angela Lorts MD, Pirooz Egthesady MD, Peter Manning MD

Two Questions:

Third Question

Camboni, et al. Serial Use of an Interventional Lung Assist Device and Ventricular Assist Device, ASAIO J 2010.

Berlin ECMO Oxygenator

“bECMO”

2011 Berlin Experience at Cincinnati Children’s

• 2011: n=7

5 successfully transplanted

1 converted back to ECMO, H Tx, died

1 converted back to ECMO, died

Patient BackgroundMale Infant with Barth Syndrome (BTHS)

• Rare (1 in 300,000 births) genetic disorder characterized by:• Cardiomyopathy (dilated or hypertrophic)• Neutropenia• Muscle hypoplasia & weakness• Growth delay• Mitochondria dysfunction• X-linked

Patient Background

• Presented at 3 days life in cardiogenic shock• Maximum inotropic support• Routine genetic evaluation was normal• End organ dysfunction persisted• Further genetic testing revealed BTHS• Prolonged hospitalization• Improved on medical CHF management.• Discharged to home

Patient BackgroundAt 1 yr of life (7.5 kg, 66cm)

• Dilated Cardiomyopathy, left ventricular non compaction, Barth Syndrome

• Cardiac function declined; EF 12%• Increased CHF symptoms• Re-admitted to CCU & listed for H Tx• V-tach, deteriorating CO on max inotropic

support, elevated Creat • Urgent VAD placement

Patient ManagementCBP & LVAD Placement

• CPB initiated 2 hour pump run• Berlin 10mL LVAD pump• 6 mm LV apex and Ao cannulae• CPB terminated

Patient ManagementLVAD only

• Return normal sinus rhythm• Borderline hemodynamics• Intraoperative TEE: ↓↓↓ RV function• Resulted in poor LVAD filling

Patient Management+ RVAD = Bi-VAD

• Returned to CPB; 1hr 6 min• Placed Berlin 10mL RVAD pump• 6 mm RA and PA cannulae• CPB terminated

L ♥

R ♥

6mm from RA

6mm to PA

6mm from Apex

6mm to Ao

RVAD

10 mL

LVAD

10 mL

Berlin biVAD Circuit

Patient ManagementBiVAD Performance• After initiation biVAD, pt received numerous

blood products & Factor VII• Pulmonary hemorrhage→ Poor Oxygenation• High airway pressures→ ↑PVR• ↓RVAD ejection• ↓LVAD filling

Patient ManagementOxygenator Placement• Surgeon decided to splice in Quadrox

pediatric oxygenator• Obtained a blood primed Quadrox from

ECMO team• He built it and we pumped!

L ♥

R ♥

6mm from RA

6mm to PA

6mm from Apex

6mm to Ao

RVAD

10 mL

LVAD

10 mL

bECMO Circuit

OXY

RVAD

LVAD

QUADROX OXYGENATOR

FLOW PROBE

PRE MEMB PRES

POST MEMB PRES

HEAT EXCHANGER

From RA to RVAD

To Quadrox

R ♥L ♥

To PA

bECMO Settings

• Berlin Flow: 1 LPM (10mLpump x 100bpm)• MODE: Synchronous• RATE: 100 bpm• L & R DRIVE PRESS systole: 180 mmHg• L & R DRIVE PRESS diastole: -50 mmHg• % SYSTOLE: L=40

R=50

Berlin

bECMO Settings

• Actual Flow: 0.7 – 0.8 LPM (Transonic Q probe)• prePres = 50 mmHg (ave)• postPres 25 mm Hg (ave)• Sweep: 1 – 2 LPM (begin – ↑ - oxy off)• FiO2: 100% - 0% (begin – ↓ - oxy off)• bECMO and Vent settings adjusted to maintain

normal hemodynamics

Quadrox & Ventilator

Patient ManagementbECMO

• Saw IMMEDIATE improvement in patient’s hemodynamics and ventilation.

• Transferred to CCU with an open chest

BLENDER

H/C

IKUS

OXY

Patient Management23 Day Odyssey Begins

Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13

Day 14 Day 15 Day 16 Day 17 Day 23

Week 1

Week 2

Week 3

bECMOQ=0.6LPMIn-houseCCP 24/7

Charting q 2 hr

bECMOQ=0.7LPM

Sweep=1LPMFiO2=70%

Sweep Off thru OxyCCPs NOT in house

Oxy#2 AddedIn-houseCCP 24/7

Charting q 2 hr

Both PumpsChanged Out

Oxy NOT ChangedClot Inflow Oxy

RVAD Clot

CCPs & ECMOStaffing

7a-7p CCPs7p-7a ECMO

Chest ClosedNo ∆ bECMO

Begin ↓ SweepFiO2 21%

StableH Tx!!

Sm ClotInflowOxy

Oxy RemovedBerlin Only

bECMOQ= 0.8 LPM

Sweep=1LPMFiO2=50%

↑TrainingRNs & ECMO

Oxy #2 RemovedBerlin Only

Day 65 Discharged!

Time Line

bECMO ChallengesPersonnel Logistics

• 15 ECMO Specialists & 4 CCPs• Perfusion was in house 24/7 without

interruption to the OR schedule• Recap:

• Days 0-4 (CCPs 24/7)• Days 5-6 (break)• Days 7-13 (CCPs 24/7)

bECMO Challenges

Personnel Logistics

• CCPs in-house NOT bedside• CCPs checked every 2 hours.• Dilemma:

• ECMO team was not familiar with the Berlin.

• Perfusion had limited experience with Quadrox.

• Bedside nurse accustomed to 24/7

bedside ECMO Specialist.

bECMO ChallengesPersonnel Logistics• Solution:

• Training – ECMO team & CCU RNs

• Days 14 – 17 Shared Staffing with ECMO Specialists

• Perfusion 7a.m. to 7 p.m.• ECMO specialist 7p.m. to 7 a.m.

It Took a Village!

bECMO ChallengesCircuitry• Question: Why didn’t we use two circuits:

Berlin + V-V ECMO?• Answer: Real Estate: how to cannulate• Other concerns:

• Possibly needing very long-term support to H Tx• Preserving end organ function w/ pulsatillity (saw

on arterial pressure line tracing and pulse oximetry monitor)

bECMO ChallengesCircuitry Insight• Quadrox pedi ¼ inch connections• 10mL Berlin pumps ¼ inch connections• Made the slice easy• Larger Berlin pumps take 3/8 inch

connections

bECMO ChallengesAnticoagulation

• Didn’t use Berlin’s Anticoag Protocols because we had the Quadrox in circuit

• Used heparin & continuous AT3 infusion• Measured unfractionated heparin levels• TEG & Platelet mapping

bECMO ChallengesAnticoagulation• Hematology rounded daily• TEG “Learning Curve”; establishing protocols• Poor correlation w/ standard coag tests• Ran Unfractioned Heparin levels lower (0.1-0.3)

than normal range (0.3-0.7) to prevent bleeding• Completely turn heparin off to ↓ bleeding• (?) Was this due to BTHS• N=7 Berlins: all pt’s coag’s were different

bECMO ChallengesKey Learnings

• A very involved Hematology Team that understands TEG, PLT mapping and PLT aggregation is vital.  

• Communication between disciplines is essential.

• Training is critical.• Patience, patience, patience.

Conclusion

Don’t be afraid to think “outside the box”

• Be Safe• Be Creative• Be Innovative

It just may …

Save a patient’s life!

ThanksbECMO is a “team sport”

• Great Cincinnati team of perfusionists, ECMO specialists, RNs, and doctors

• Colleagues around country helped via e-mail and phone

Discussion