Ambulatory ECMO Don Hayes, Jr., MD, MS Section of Pulmonary Medicine Nationwide Children's Hospital The Ohio State University
Disclosures No conflicts of interest No financial relationships Funding Cystic Fibrosis Foundation National Institutes of Health
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
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
ECMO Capabilities Components Oxygenator O 2 CO 2 Pump Cardiac output Perfusion O 2 delivery Heat exchanger Temperature
VA-ECMO Right internal jugular vein drainage Right carotid artery infusion
Two-site VV-ECMO Right common femoral vein drainage Right internal jugular vein infusion
Bicaval Dual-Lumen Cannula
Bicaval Dual-Lumen Cannula Placement
Single-site VV-ECMO
Single-site VV-ECMO
Confirmation of Cannula Placement Hayes et al. Am J Respir Crit Care Med 2013;187:1395-6
Ambulatory VV-ECMO Hayes et al. J Cyst Fibros 2012;11:40-5
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 < 0.001 Total N = 17,441 ECMO N = 198
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 = 0.202 Total N = 2732 ECMO N = 62
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 < 0.001 Total N = 7701 ECMO N = 89
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 < 0.001 Total N = 7008 ECMO N = 47
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 = 0.250 Total N = 585 ECMO N = 17
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
NCH Program Development On-site Consultation
ECMO Transport
Evolution of ECMO Transport
Current Transport
Pediatric Ambulatory ECMO & Rehabilitation Hayes et al. Lung 2014;192:1005
Swallow Study & Oral Nutrition
School & Play Time
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
Extended VV ECMO 8 years of age on extended VV ECMO Pulmonary hypertension (PH) Failure of right ventricle (RV)
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
Severe RV dysfunction
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
Disease Process Matters
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?)
The Future? - PROTEK Duo CardiacAssist, Inc.
TandemHeart Pump CardiacAssist, Inc.
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
Long-term Benefits
Acknowledgements NCH OSU