ECMO: When, Where, and by Whom?

Joseph B. Zwischenberger MD

Johnston-Wright Professor

Chairman: Department of Surgery

Surgeon-in-Chief UK Healthcare 859-229-6635 (mobile)

jzwis2@uky.edu

The University of Kentucky

Lexington, Kentucky

Presenter Disclosure Information

Research supported in part through

• Competitive funding:

National Institutes of Health (SBIR,STTR,T-32)

• Contracts: MC3, Ann Arbor Mi Exotherm, Lexington Ky W-Z Biotek, Lexington Ky Maquet Patent: Avalon Elite™ (4 more, 3 pending) Novalung Free App: “Zwisch Me”

Joseph B. Zwischenberger, M.D.

Bartlett/Zwischenberger 1984

Z-Bergerism #12

Innovation is never

evidence-based

Integrated MCS/ambulatory ECMO

programs: … improve survival over institutions w/o ECMO … transplant patients who would die on the waitlist … salvage patients who would not be resuscitated … provides a regional public health resource … generates research on regenerative med … and, one of the highest financial margins in the hospital~ $20,000 profit per ECMO case

Indications for ECMO

Acute, severe, cardiac or pulmonary

failure unresponsive to optimal

management, with recovery expected

in 2-4 weeks, months or when an

acceptable organ is available

Neonatal resp ~ 75%

All others ~ 50%

Bridge to Transplt ~ 80%

ECMO Runs by Year

0%

20%

40%

60%

80%

100%

Card (16 years and over)

Card (1 year < 16 years)

Card (31 days < 1 year)

Card (0 - 30 days)

Adult Pulm

Ped Pulm

Neo Pulm

ASAIO (2013) 59(6):642-50

Problems with ECMO … Perceived “Intensity”

⬇

“50% of patients die in a relatively acute manner with

progressive symptoms of less than one month…

restrictive physiology is a poor predictor of mortality”

King et al (2005) Chest 127:171

Role for ECMO in acute exacerbations

of a progressive, lethal lung disease …?

interstitial lung disease …

5 7 36 78190

419

704

921

1088

12231336

1452146214901629

1693

18821932

2071

23842448

2769

1357

2716

0

250

500

750

1000

1250

1500

1750

2000

2250

2500

2750

3000

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Num

ber

of T

rans

plant

s

Bilateral/Double Lung

Single Lung

1st decade: “experimental” (science)

2nd decade: “learning curve” (patient)

3rd decade: “QAPI” (program)

(457)

1963 Hardy (Univ of Miss …. survival 18 days)

1974 Veith (SFGH … on ECMO, pediatric, 10 days)

1983 Cooper (#45, Toronto … on ECMO, 6 months)

Case series outcomes versus UNOS registry data since 2005: LAS>50, bilateral lungs only, diagnostic codes restricted to IPF, CF, and PHTN UNOS without ECMO (n=2971), red UNOS with ECMO (n=49), purple All comparisons significantly different (p<0.001)

Hoopes, Zwischenberger et al (2013) JTCVS

Outcomes for ECMO bridge to transplant …

Should anyone die

from acute lung

injury?

ECMO as a bridge for

regenerative medicine

VENOVENOUS ECMO Single, Double Lumen Cannula

For total gas exchange alone

Zwischenberger/Drake Prototype ASAIO J 1984

Kendall 1989

Oxygen transfer

Carbon Dioxide Removal

CO2 Removal

CO2 removal and O2 transfer are

uncoupled:

– CO2 is transferred across the

membrane gas exchanger

– Low Frequency Ventilation:

O2 diffuses across the native lungs

Ted Kolobow 1977

AVCO2R: Carbon Dioxide Removal (get the bad air out) with a low-resistance gas exchanger in a simple arterio-venous shunt

Zwischenberger 1996

percutaneous

cannulation

of femoral artery

(10-12 Fr) and

vein (16-18 Fr)

Flow 800-1000

ml/min for

CO2 Removal

Arteriovenous CO2 Removal = PECLA NOVALUNG (Europe): Survival 70%

>3000 patients

Impact of CO2 Homeostasis

CO2 flux is greatly reduced by AVCO2R,

and may be important in:

• organ tissue neutrophil apoptosis

• resolution of inflammation

• maintaining a normal alveolar milieu

Zwischenberger et. al. Ann Surg 2007;246:512-521

The higher pump flow, the more recirculation (♦)

Effective flow (■) no longer increases

as pump flow increases

VV Triple site

cannulation

–Minimizes

recirculation

–maximizes

venous

drainage

–improves gas

exchange

2003

Avalon Elite® Catheter Placement:

image guidance required

Flouro insertion with ECHO positioning

Wang/Zwischenberger 2007

Newborn with Meconium Aspiration on Avalon

Elite® VVDL ECMO 6 days: No Recirculation

Blue blood out Red blood in

2009

United Kingdom H1N1

ECMO vs Conventional care

• 69 ECMO patients in 4 centers

• Matched pairs study, 3 methods

ECMO CC survival %

• Individual 77 48

• Propensity score 76 53

• Genmatch 76 49

• Conclusion: ECMO survival 76%

Conventional Care 49%

“To clinicians who have witnessed first-

hand ECMO’s ability to salvage an

unstable life that would presumably be

lost without it, today’s study will represent

the sentinel paper on adult ECMO for

years to come. After all, 63% of patients

who were dying survived to 6 months with

ECMO referral…”

Zwischenberger JB, Lynch JE; Will CESAR

answer the adult ECMO debate? The Lancet 2009; 374

CESAR Trial

Goal: Ambulatory Paracorporeal Artificial Lung

Grant Concept 2003

IVC

SVC

RV

TV

IVC

SVC

56 yo idiopathic pulmonary fibrosis:uncomplicated bilateral lung tx 3/08 12/08 Trichosporon pneumonia, post-infectious obliterative bronchiolitis. Listed for redo transplant Feb ’08.

Alert 3-3-09 Chuck Hoopes (UCSF ): the

first Ambulatory Lung Assist patient using

Avalon Cannula, Quadrox and Centrimag!!

Total gas exchange - no recirculation

Exercise at the bedside

Securing cannula for ambulation and sterilization

VA ECMO

“Sport Model”

Optional V-VA or

WEAN to DLC VV

All configurations

allow ambulation

Bacchetta 2012

This is ECMO ?

“walking ECMO”…dual lumen

Avalon VV (hypoxia,

hypercapnea secondary BOS..

to redo BLTx)

“ambulatory right heart bypass”…PA to LA

cannulation (RV failure, hypoxia, PHTN s/p PEA..to BLTx)

“walking bypass”…RA to Ao cannulation

(BiV failure, PHTN s/p PEA..to HLTx)

“walking bypass”… RA to Ao cannulation

with pump/oxygenator (BiV failure, PHTN s/p

PE..to HLTx)

28 angled metal tip

RA outflow

10 mm Dacron PA

inflow

graft

The “oxyRVAD” … RA to PA with pump/oxygenator

Pumpless ExtraCorporeal Lung Assist ( PA-LA)

“pulmonary bypass”… supra-systemic pulmonary pressures

do not require a centrifugal pump …

Fem-Fem

Walking VA

• V-AV support

• Partial VA

ECMO/Partial VV

ECMO

SVC

EuroELSO 2015: ambulatory

FEM-FEM ECMO is feasible

*prevent barotrauma and

activation of

inflammatory mediators

*Limit end organ injury

*avoid sedation and

muscle atrophy (frailty)

VV DLC ECMO

pre BLTx (cystic fibrosis)

Does anyone with severe respiratory failure really

benefit from mechanical intubation and positive

pressure ventilation? …..With ECMO…..

20/22 consecutive ambulatory ECMO adult

patients are alive to 6 months

Keshavjee ECMO Red Book, 4th edition, 2011

Selection of ECLS Support Mode /Configuration

Pediatric Ambulatory ECMO patient

AATS 5/2015: 12 ECMO talks

AATS Guidelines: Bridge to transplant

and Extracorporeal lung support:

Ambulatory ECMO recommended

(Bacchetta and Cypel 2015)

SUMMARY OF RECENT REPORTS* CHRONOLOGICALLY OF THE USE OF ECMO AS BRIDGE TO LUNG TRANSPLANT (*SERIES WITH MORE THAN 10 PATIENTS)

REFERENCE YR PATIENTS

DURATION

(RANGE)

MODE OF

ECLS BRIDGE (%)

SURVIVAL

1 YR (%)

Hoopes 2013 31 13.7b (2-53) VV DLC (10)

VV (1)

VA (10)

PA–LA (2)

RA–Ao (3)

Comb 5)

87

Dellgren 2015 20 9 (1-229) VV DLC (3)

VV (11)

VA (6)

80 62

Hayanga 2017 49 NA Not specified NA 80

Hoetzenecker 2017 71 10 (0-95) VV DLC (23)

VV (7)

VA (7)

PA-LA (9)

ECCO2R (12)

Comb (13)

89 66

Todd 2017 12 2.2 (0.7-16.5) VV DLC (9)

VV (2)

VA (1)

100 100

Unconventional Institutional

Volume Outcome Associations in

Adult ECMO in the US

No significant survival difference

between Low, Medium and High

volume ECMO programs in bridge to

Heart or Lung transplant patients

McCarthy et.al. Presented at STSA 11/15

Ambulatory ECMO – A Surgical

Innovation for ARDS

While the ARDSnet trial shows superiority of

low tidal volumes compared to higher tidal

volumes, in patients receiving positive pressure

ventilation, spontaneously breathing patients

will not generate injurious tidal volumes or

airway pressures, particularly when their gas

exchange abnormalities are corrected by ECMO.

Bharat, Pham, Prasad; JAMA Surgery, 5/16,151:5

Hybrid ECMO for Heart and Lung Failure

Many now using

Distal Limb

perfusion

routinely

2016

eCPR: ER ECMO Survey of Centers participating in

Extracorporeal Life Support Organization

(ELSO)

• Over 33% of centers that submit adult

ECMO perform ED ECMO

• CT, Emergency Med, Cardiology, Vascular

• Successful resuscitation estimated at 40%

Resuscitation 107 (2016) 38-46

Thiagarajan RR, et al. ASAIO 2017, 63(1):60-67

40%

30%

(26 patients)

54% neurologically

intact survival

ECPR

13% increased 30-day survival

Better neurological outcome

ECMO for cariogenic shock

33% higher 30-day survival than IABP

Similar to Tandem Heart/Impella

Patient Selection for Resuscitation

Potentially reversible cardiopulmonary failure

No coexisting terminal illness

No recent or active intracerebral hemorrhage

No visceral hemorrhage

No DNR order

ECMO Transport

• Safety and Outcomes of Mobile ECMO Using a

Bicaval Dual-Stage Venous Catheter

– Improved in hospital survival 86% (44 pts) vs

Conventional ECMO 79% (126 pts) ASAIO J 2017; 63:351-355

• Transportation of Patients on ECMO: Center

Experience and Literature Review

– 38 manuscripts plus experience (1481 pts)

– Survival: Adult (62%) Pediatrics (68%)

Ann Intensive Care (2017) 7:14

ECMO FUTURE Catheter based Technology (Ambulatory)

– Recipient Support

– Donor Support: DCD

– Organ Block Support : Lung in a Box

Transplantation

Neonates, Children, Adults

Acute Severe Respiratory failure

Acute Cardiac support

ER

Transport

Resuscitation/Shock

Will play for drinks and tips

You should ALWAYS listen to a harmonica player

ECMO: When, Where, and by Whom?

Joseph B. Zwischenberger MD

Johnston-Wright Professor

Chairman: Department of Surgery

Surgeon-in-Chief UK Healthcare 859-229-6635 (mobile)

jzwis2@uky.edu

The University of Kentucky

Lexington, Kentucky