Suni Jose*

Senior perfusionist, Heart & Lung Transplant Team, Kauvery Hospital, Chennai, India

*Correspondence: +91 98414 44616

Background

Extracorporeal membrane oxygenation, also known as extracorporeal life support, is an extracorporeal technique of providing prolonged cardiac and respiratory support to patients whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life.

People can stay on ECMO anywhere from days to weeks. The length of time that a person will spend on ECMO depends on why they need this treatment.

va-ecmo-bridge

qIs ECMO lifesaving?

ECMO is a therapy used to treat people with life-threatening heart and lung failure. ECMO involves the use a machine to replace some of the functions of a patient’s lungs or heart, or both simultaneously. While ECMO therapy can be life-saving, it is not itself a treatment.

ECMO is a form of cardiopulmonary life-support, where blood is drained from the vascular system, circulated outside the body by a mechanical pump, and then reinfused into circulation. While outside the body, haemoglobin becomes fully saturated with oxygen and CO2 is removed.

There are different types of ECMO that can be initiated based on the treatment needed.

There are two types of ECMO:

1) veno-venous (VV)

2) veno-arterial (VA)

Components of ECMO include- The ECMO console, Centrifugal Pump, Oxygenator, Circuit tubing with cannula, Heater-Cooler unit, Gas exchange device.

veno-arterial

Case Presentation

Mr. X was admitted to Kauvery Hospital on 04/01/2023 in the emergency department. He was diagnosed with Anterior wall myocardial infarction, cardiogenic shock and severe left ventricular dysfunction with ejection fraction of 15%. He had acute pulmonary oedema with recurrent ventricular tachycardia. Intra-aortic balloon pump was inserted but failed.

Following this Impella (which is a type of ventricular assist device) was inserted on 05/01/2023. He was shifted to ICU, urine out-put and other parameters improved. Suddenly Impella stopped on 09/01/2023., electively IABP was inserted and supports were restarted.

Patients condition was discussed with heart and lung transplant team and decided for orthotopic heart transplant Patient became hemodyanamically unstable and his systemic pressure was low with high inotropes. he was electively intubated and second Impella was inserted on 13/01/2023 through 7fr Axillary artery Dacron graft and maintained 3.5 litres /min flow. He was extubated on 14/01/2023 with all supports tapered and stopped. He was hemodyanamically stable with good urine output. Now the only option available for him was a transplant or an LVAD at the earliest.

Impella, according to FDA guidelines, can run only for 5-9 days. So the patient was registered in the transplant priority list and LVAD was planned on 26/01/2023 in case we do not get an appropriate heart donor.

The second Impella failed on 23/01/2023. so, the only option available was ECMO as it can support the patient for months. The patient was shifted to operation theatre VA ECMO was initiated through left Axillary artery dacron graft and left femoral vein and maintained 3 litres/min flow and shifted to ICU. The patient was stable and comfortable on ECMO.

On 24/01/2023 we got an alert for a suitable heart donor. patient and family were explained regarding the same and they agreed to go ahead with surgery. After informed consent and anesthesia fitness, patient underwent orthotopic heart transplant surgery 24.01.2023 with blood group matched and BSA matched donor and ECMO was weaned off.

After procedure, patient was shifted to ICU with minimal inotropic and nitric oxide support. Nitric oxide gradually tapered off and patient was extubated on POD-1.

Conclusion

So, in this case, ECMO was used as the bridge for the transplant. If ECMO was not initiated at the right time we could have lost the patient.

Now to bring out the advantages of ECMO:

  1. ECMO is much cost-effective when compared to Impella. ECMO cost for ten days are around 10 lakhs whereas for Impella it costs around 30 lakhs.
  2. ECMO can be used for 1-3 months whereas Impellas can be used only for 5-10 days.
  3. There are many types of ventricular assist device used as a bridge to transplant, but at present ECMO is the favored therapy.
  4. If not for ECMO this patient could have had a negative outcome. Thanks to modern day innovations like ECMO which acts as a bridge for transplant till an appropriate donor is available.
Suni-Jose

Ms. Suni Jose

Senior perfusionist, Heart & Lung Transplant Team

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