Technical and biological advances in ECMO

1. Technical and biological advances in ECMO • Maria Laura Costantino New Perspective in ECMO 2012 III International Meeting Milan, 5 October 2012

2. Extracorporeal Membrane Oxygenation(ECMO) • ECMO is the use of a modified extracorporeal circuit to provide temporary mechanical support (respiratory and/or cardiac) to patients failing conventional intensive therapy. • ECMO has brought the technology of cardiopulmonary bypass to bedside under the management of ECMO specialists and intensive care physicians.

3. History 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system.

4. History 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system. Dr & Mrs Gibbon with their CPB machine

5. History 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system. 1950 – Early Developements of CPB. 1956 – GHA Clowes Jr. – Plastic Membrane Oxygenator. 1957 – K Kammermeyer – Use of thin Silicone Membranes. Early ’60s – T Kolobow designed his “Membrane Lung”. 1972 – JD Hill reported first successful case of prolonged extracorporeal support in humans: Adult ECMO

6. History

7. History • 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). • 1930 – JH Gibbon - First extracorporeal circulation system. • 1950 – Early Developements of CPB. • 1956 – GHA Clowes Jr. – Plastic Membrane Oxygenator. • 1957 – K Kammermeyer – Use of thin Silicone Membranes. • Early ’60s – T Kolobow designed his “Membrane Lung”. • 1972 – JD Hill reported first successful case of prolonged extracorporeal support in humans: Adult ECMO • 1975 – RH Bartlett - First Successful Neonatal ECMO • 1986 – L Gattinoni - 50% Survival in Adult ECCO2R • 1989 – ELSO Registry

8. History From then on, over and over increasing number of centres are performing either adult or neonatal ECMO • 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). • 1930 – JH Gibbon - First extracorporeal circulation system. • 1950 – Early Developements of CPB. • 1956 – GHA Clowes Jr. – Plastic Membrane Oxygenator. • 1957 – K Kammermeyer – Use of thin Silicone Membranes. • Early ’60s – T Kolobow designed his “Membrane Lung”. • 1972 – JD Hill reported first successful case of prolonged extracorporeal support in humans: Adult ECMO • 1975 – RH Bartlett - First Successful Neonatal ECMO • 1986 – L Gattinoni - 50% Survival in Adult ECCO2R • 1989 – ELSO Registry

9. ECMO Types The type of ECMO depends on the patient’s underlying cardiac function. Veno-Arterial (V-A) ECMO Veno-Venous (V-V) ECMO • Provides support for severe cardiac and respiratory failure, most commonly after cardiac surgery. • Induces high hemodynamic disturbances depending on the chosen return access sites. • Can be used as a bridge to cardiac recovery or to another destination therapy. • Provides support for severe respiratory failure when reasonable heart function is assessed. • Induces low hemodynamic disturbances. • 1 or 2 access cannulae can be used depending on the bypassed blood flow.

10. ECMO Types Veno-Arterial (V-A) ECMO Veno-Venous (V-V) ECMO Second Access Cannula SVC Return Cannula FA Return Cannula IVC Access Cannula FV Access Cannula IVC

11. ECMO Circuit Equipment • Outflow cannula • Inflow cannula • Pump • Oxygenator • Lines Patient Gas Source Main Issues Membrane Lung • Efficacy • Priming Volume • Haemolysis • Compatibility • Duration Pump

12. ECMO main technical advances are in 4 areas • 1) A move from VA to VV ECMO: helped by the widespread use of a wide size range of double-lumen veno-venous cannulae. DL VV catheter Return (arterial) lumen Outflow (venous) lumen

13. ECMO main technical advances are in 4 areas • A move from VA to VV ECMO: helpedby the widespreaduse of a wide sizerange of double-lumenveno-venous cannulae. • A move from roller tocentrifugalpumpsthat do notdamage the redcells (mostmainpumpmanufacturershavesystems). Centrifugal Pump Drive Unit Roller Pump Console Centrifugal Pump Head Roller Pump Head Centrifugal Pump Console

14. ECMO main technical advances are in 4 areas • A move from VA to VV ECMO: helpedby the widespreaduse of a wide sizerange of double-lumenveno-venous cannulae. • A move from roller tocentrifugalpumpsthat do notdamage the redcells - mostmainpumpmanufacturershavesystems. • A switch from silicone membrane oxygenatorstopolymethylpentenehollow fibre ones. Silicone membrane oxygenator unravelled

15. ECMO main technical advances are in 4 areas • A move from VA to VV ECMO: helpedby the widespreaduse of a wide sizerange of double-lumenveno-venous cannulae. • A move from roller tocentrifugalpumpsthat do notdamage the redcells - mostmainpumpmanufacturershavesystems. • A switch from silicone membrane oxygenatorstopolymethylpentenehollow fibre ones. • Miniturisation of circuits:all the abovehaveallowedcircuitminiturisation, havefacilitatedtransport on ECMO and haveallowedustorunwithmuchlessHeparin, thusreducingbleedingrisk.

16. Thank you for your attention