Ambulatory ECMO. Don Hayes, Jr., MD, MS Section of Pulmonary Medicine Nationwide Children's Hospital The Ohio State University

Transcription

1 Ambulatory ECMO Don Hayes, Jr., MD, MS Section of Pulmonary Medicine Nationwide Children's Hospital The Ohio State University

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5 Disclosures No conflicts of interest No financial relationships Funding Cystic Fibrosis Foundation National Institutes of Health

6 Objectives Review outcomes of extracorporeal membrane oxygenation (ECMO) at time of lung transplantation (LTx) Review our efforts using ambulatory ECMO as a means of transport & bridge to LTx Discuss complications of extended venovenous (VV) ECMO

7 Background ECMO Venoarterial (VA) vs Venovenous (VV) Prolonged bypass for gas exchange Reversible cardiac or respiratory failure Refractory to optimal conventional therapy Components Pump Oxygenator Heat exchanger Alarms/safety systems

8 ECMO Capabilities Components Oxygenator O 2 CO 2 Pump Cardiac output Perfusion O 2 delivery Heat exchanger Temperature

9 VA-ECMO Right internal jugular vein drainage Right carotid artery infusion

10 Two-site VV-ECMO Right common femoral vein drainage Right internal jugular vein infusion

11 Bicaval Dual-Lumen Cannula

12 Bicaval Dual-Lumen Cannula Placement

13 Single-site VV-ECMO

14 Single-site VV-ECMO

15 Confirmation of Cannula Placement Hayes et al. Am J Respir Crit Care Med 2013;187:1395-6

16 Ambulatory VV-ECMO Hayes et al. J Cyst Fibros 2012;11:40-5

17 ECMO at LTx in Adults ( 18 yrs old) Hayes et al. J Heart Lung Transplant (In press) Log-rank test: Chi-square 1 : 27.25, p < Total N = 17,441 ECMO N = 198

18 ECMO at LTx in 18 to 39 yrs old Hayes et al. J Heart Lung Transplant (In press) Log-rank test: Chi-square 1 : 1.63, p = Total N = 2732 ECMO N = 62

19 ECMO at LTx in 40 to 59 yrs old Hayes et al. J Heart Lung Transplant (In press) Log-rank test: Chi-square 1 : 17.16, p < Total N = 7701 ECMO N = 89

20 ECMO at LTx in 60 to 81 yrs old Hayes et al. J Heart Lung Transplant (In press) Log-rank test: Chi-square 1 : 19.68, p < Total N = 7008 ECMO N = 47

21 ECMO at LTx in < 18 yrs old Hayes et al. Pediatr Transplant 2015;19:87-93 Log-rank test: Chi-square 1 : 1.32, p = Total N = 585 ECMO N = 17

22 Pediatric Lung Transplant Centers Nationwide Children s Hospital Lucile Packard Children's Hospital * * Children s Hospital of Los Angeles St. Louis Children s Hospital * * * * * * Boston Children s Hospital Children s Hospital of Philadelphia Children s Hospital of Pittsburgh * Texas Children s Hospital Cincinnati Children s Hospital Medical Center

23 NCH Program Development On-site Consultation

24 ECMO Transport

25 Evolution of ECMO Transport

26 Current Transport

27 Pediatric Ambulatory ECMO & Rehabilitation Hayes et al. Lung 2014;192:1005

28 Swallow Study & Oral Nutrition

29 School & Play Time

30 Benefits of ECMO at LTx For children, adolescents & young adults Extend life to allow for organ availability Potentially expedite organs Patients with lung allocation score Mean wait time to transplant = 14 days Rehabilitate while waiting Mean post-ltx length of stay = 30 days

31 Extended VV ECMO 8 years of age on extended VV ECMO Pulmonary hypertension (PH) Failure of right ventricle (RV)

32 With success comes new challenges... 8 YO develops irreversible pulmonary fibrosis from ARDS secondary to drug reaction Transferred to NCH for LTx evaluation Trach, VV-ECMO support (48 days prior to arrival) Supported for additional 37 days Awake, mobilized, rehabilitated Develops PH & RV dilation, clinically well until arrest (ECMO day #84 successfully resuscitated & converted to VA-ECMO Supported additional 2 days until CNS injury precludes LTx, support withdrawn

33 Severe RV dysfunction

34 RV is NOT an LV RV feature Impact Thin walled Easier to volume overload, more influenced by afterload Low pressure Pericardial & thoracic pressure exert more influence Abnormal, nonuniform shape Different coronary perfusion pattern Interventricular interactions Difficult to quantify with imaging & measure volume/function Elevated RV pressures may result in ischemia LV volume/function influences RV function via septum

35 Disease Process Matters

36 Differences in Disease Process Chronic lung disease (Cystic fibrosis) Long standing pulmonary changes RV time to remodel/hypertrophy respond to stress Acute lung injury/ards Acute changes to pulmonary vasculature No time for RV adaptation Do we hurt them with additional RV stress (i.e. exercise?)

37 The Future? - PROTEK Duo CardiacAssist, Inc.

38 TandemHeart Pump CardiacAssist, Inc.

39 ECMO at time of LTx Conclusions Younger patients have higher survival Extended VV-ECMO Close monitoring for PH & RV failure Exit strategy Atrial septostomy, conversion to VA-ECMO Prospective research needed Biomarkers for PH & RV failure Impact of VV-ECMO on pulmonary physiology

40 Long-term Benefits

41 Acknowledgements NCH OSU

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