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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Dr. Arnaud Roussel
Prof. Nawwar Al-Attar
Dr. Feras Khaliel
Extracorporeal Membrane Oxygenation (ECMO) is a form of extracorporeal life support (ECLS) to provide prolonged but temporary support of heart and/or lung function that can last from days up to a few months, depending on the patient’s condition. It can be considered an adaptation of conventional cardiopulmonary bypass (CPB), i.e. the heart lung machine, for prolonged cardiopulmonary support using intrathoracic or extrathoracic cannulation.
The system consists of a circuit - often heparin-coated- composed of 1) a membrane oxygenator, 2) centrifugal pump, and if patient needs temperature modification, 3) a heat exchanger. The centrifugal pump has a non-occlusive design that promotes laminar flow, improving blood handling capabilities and decreasing blood trauma often associated with extracorporeal circulatory support experienced with cardiopulmonary bypass. Coated circuits provide a more biocompatible surface that minimises platelet activation and systemic inflammatory response. It also seeks to reduce or eliminate the heparin requirement allowing the ECMO circuit to be used for several days.
The two types are different in terms of effects on the circulation; these are detailed in table 1. There is 1) veno-arterial (VA) ECMO - supports the heart and lungs: requires two cannulae-1) one in right atrium via peripheral vein and 2) one in an artery and the 2) Veno-venous (VV) ECMO – supports the lungs only: requires one cannula in the jugular vein or a second cannula through the femoral vien.
Table 1. Types of ECMO in regards to their effects on circulation.
ECMO support is useful when 1) the primary lung injury is accompanied by oxygen toxicity or barotrauma caused by mechanical ventilatory support or 2) the primary underlying cardiac insult is potentially reversible. The following conditions are possible indications.
Femoral arterial cannulation can be performed 1) via percutaneous Seldinger’s technique or 2) an open surgical approach.The percutaneous approach is adequate 1) when digital palpation of the femoral pulse can be obtained. It is performed under ultrasound/Doppler guidance. Percutaneous femoral cannulation carries the advantage of allowing an expeditious procedure in an emergency situation. After heparinisation, puncture of the common femoral artery (CFA) is done, then a soft tipped guide-wire is passed through the needle. Dilatators are passed stepwise over the guide-wire to enlarge the access until the cannula size is achieved. The cannula is inserted and connected to the ECMO system (3-5).The open approach for arterial cannulation allows visualisation of the artery to ensure adequate size of cannula, proper placement, good hemostasis and opportunity to choose an alternative cannulation site in case of arterial calcifications.
Early arterial vascular complications in peripheral ECMO support remain important with rates between 3.2% and 28% occurring in case of femoral cannulation site. The most significant vascular complication reported is limb ischemia. Causes of limb ischemia after ECMO are listed in table 2.Table 2 : Etiology of ischemia after femoral artery.
ECMO requires a multidisciplinary team approach involving surgeons, anesthetists and intensive care physicians and nursing staff to achieve the best clinical outcome. There is a considerable risk of bleeding with ECMO. This is attributed to a low patient platelet count which may occur due to 1) Platelets adhering to surface fibrinogen and are activated 2) Resultant platelet aggregation and clumping causes numbers to drop.The degree of bleeding is out of proportion to the severity of thrombocytopenia and further coagulopathy is related to the continuous activation of contact and fibrinolytic systems by the circuit and the consumption and dilution of factors within minutes of initiation of ECMO. Consequently, particular attention should be made to monitoring and managing hemostasis. This includes:regular blood tests (Q6-Q8h), coagulation profile (Activating clotting time (ACT), heparin levels, activated factor X assessment), platelet count (above 50,000), hemoglobin (around 10 g/dl) and aggressive replacement of clotting factors, electrolytes, PRBC (packed red blood cells).
Extracorporeal membrane oxygenation provides short-term cardiopulmonary support <3 weeks and a bridge to decision regarding the next step which may be recovery, transplantation long-term device (ventricular assist device), or operation (CABG, pulmonary embolectomy...).
1 - Extracorporeal life support: experience. The University of Michigan. Bartlett RH, Roloff DW, Custer JR, Younger JG, Hirschl RB. JAMA 2000; 283: 904 – 908.2 - Extracorporeal membrane oxygenation, an anesthesiologist's perspective: physiology and principles Chauhan S, Subin S. Part 1. Ann Card Anaesth. 2011;14(3):218-29.3 - Extracorporeal membrane oxygenation for severe respiratory failure.Alpard SK, Zwischenberger JB. Chest Surg Clin N Am 2002;12:355-78. 4 - Extracorporeal gas exchange. Pesenti A, Zanella A, Patroniti N. Curr Opin Crit Care 2009;15:52-8. 5 - Cardiac extracorporeal life support: state of the art in 2007.Cooper DS, Jacobs JP, Moore L, Stock A, Gaynor JW, Chancy T, Parpard M, Griffin DA, Owens T, Checchia PA, Thiagarajan RR, Spray TL, Ravishankar C. Cardiol Young.2007;17 Suppl 2:104-15.6 - Outcomes of percutaneous femoral cannulation for venoarterial extracorporeal membrane oxygenation support. Roussel A, Al-Attar N, Alkhoder S, Radu C, Raffoul R, Alshammari M, Montravers P, Wolff M, Nataf P. European Heart Journal: Acute Cardiovascular Care, 2012; vol 2: 111-114.7 - Controlling intrathoracic hemorrhage on ECMO: help from Factor VIIa and VirchowRigby M, Kamat P, Vats A, Heard M. . Perfusion. 2013 May;28(3):201-6.8 - Coagulation management in patients undergoing mechanical circulatory support. Best Pract Res Clin Anaesthesiol. Görlinger K, Bergmann L, Dirkmann D. 2012;26(2):179-98.
Nawwar AL-ATTAR, Arnaud ROUSSEL, Feras KHALIEL,Department of Cardiac Surgery, Bichat Hospital, AP-HP, Paris, France.Authors' disclosures: None declared.
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