CAMPUS GROSSHADERN - HERZCHIRURGISCHE KLINIK UND POLIKLINIKHERZKLINIK AM AUGUSTINUM

ECMO as Bridge to Lung Transplant –

Ambulatory V/V&V/VA ECMO: How to do it & Building the Team

Christian Hagl

Department of Cardiac Surgery, University Hospital Munich (LMU), Germany

Disclosure: The author declares no conflict of interest

Hannover Medical School

Munich University Hospital

11/2011

Lung transplant program

Waiting list eurotransplant

LAS

The rule of ECMO in transplantation

Am J Respir Crit Care Med Vol 185, Iss. 7, pp 763–768, Apr 1, 2012

Technical Advances

The Munich Experience

0

50

100

150

200

250

2011 v-a

2011 v-v

2011 all 2012 v-a

2012 v-v

2012 all 2013 v-a

2013 v-v

2013 all 2014 v-a

2014 v-v

2014 all

ECLS/ECMO implants 2011-2014

2011 v-a

2011 v-v

2011 all

2012 v-a

2012 v-v

2012 all

2013 v-a

2013 v-v

2013 all

2014 v-a

2014 v-v

2014 all

Staff and organization

(respiratory failure)

Department of

Anesthesiology Medical Department I/

Pneumology

Department of

Cardiac Surgery

Department of

Thoracic Surgery

Department of

Cardiac SurgeryMedical Department I

(Cardiology)

Heart

Team

Staff and organization

(cardiac failure)

MUNICH

ECMO/ECLS

Network

Physicians

Nurses

Perfusionists

Scrub

nurses

Transport

specialists

Special

transporta

tion

ICU

+

CAMPUS GROSSHADERN

CAMPUS INNENSTADT

LOREM IPSUM SETUR ALARME

In-house ECMO/ECLS

Logistics + Implementation

Herzchirurgische Klinik an der LMU

Herzklinik am Augustinum

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

in-house call ECLS

Implantation by cardiac surgeon and perfusionist

alarm approx.: 200 x year (Cardiac surgeon at ICU)

locations: cathlab, emergency room and Intensive Care Unit

Herzchirurgische Klinik an der LMU

Herzklinik am Augustinum

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

Content of emergency trolley:

v-a cannulas in all sizes,

Seldinger guide wires,

material, etc.

ICU

emergency

room

cathlab

nursing

unit

in-house equipment for ECLS implantation

Clinic goes to patient

Herzchirurgische Klinik an der LMU

Herzklinik am Augustinum

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

Decision making process after ECLS implantation

Heart

Team

Herzchirurgische Klinik an der LMU

Herzklinik am Augustinum

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

in-house call ECMO

Anesthesiologist or cardiac surgeon and perfusionist

alarm approx.: 100 x year (anesthesiologist at the ICU)

locations: Intensive Care Unit

Decision for implantation in transplant candidates

CAMPUS GROSSHADERN

CAMPUS INNENSTADT

LOREM IPSUM SETUR ALARME

External ECLS/ECMO

Logistics + Implementation

Herzchirurgische Klinik an der LMU

Herzklinik am Augustinum

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

external emergency call (ECMO/ECLS)

request to the attending senior physician

doc to doc conversation

implantation in external hospitals by experienced ECLS team

(ECLS: cardiac surgeon + perfusionist)

(ECMO: anesthesiologist or cardiac surgeon + perfusionist)

Transport by cardiac surgeon +/- anesthesiologist + perfusionist

Herzchirurgische Klinik an der LMU

Herzklinik am Augustinum

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

transport equipment

content emergency trolley:

v-a cannulas in all sizes

Seldinger guide wire, ACT messurement,

material, etc.

technical requirements 24/7 out-side use

Herzchirurgische Klinik an der LMU

Herzklinik am Augustinum

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

upward 4 G

foreward 16 G

sideward 8 G

downward 20 G

backward 1.5 G

specifications of grafity – load direction

ECMO/ECLS fixation

european aviation savety agency EASA, www.easa.europa.eu

Heart Lung Renal Assist

The clinic to go.

V-V ECMO in hypoxemic or hypercapnic respiratory failure

V-A ECMO in right ventricular failure or profound hypoxemia

Awake ECMO preferred when possible

Comfort oriented cannulation (e.g. Avalon cannula)

Choice of

ECMO procedure in potential

Ltx pts

WHEN?

Bridge to Lung Transplant

• Refractory hypercapnic and/or hypoxic respiratory failure:

paCO2>80 mmHg and/or PaO2/FiO2<80 mmHg despite maximum

noninvasive support

• Right ventricular failure refractory to prostacyclin treatment and

catecholamines with secondary organ dysfunction

• Young patients, absence of multi-organ dysfunction, good prospects for

rehabilitation after LTx

The Munich Experience

n

11/2011-12/2014

Age 50+/-14 years, 39% female

65%

71.1%

23.8%

The Munich Experience

V/V&V/A ECMO/ELCS

as Bridge to LTx

Weig et al. Clin Transplant 2013

Goals for a sucessful

ambulatory ECMO/ECLS

program

Competence center

Trouble shooting concepts

Definition of minimum acceptable volume

Decision making rules

Adaequate funding and reimbursement

Political support

Highly motivated staff

Frequent training and education

Interdisciplinary thinking

Data base registrations

Ethics

WHEN?(Relative) contraindications

Multi-organ-failure

Neurological deficit/unclear neurological situation

Bleeding

Malignancy

(Severe arterial occlusive disease)

(HIT type II)

(Septic shock)

Absolute contraindications? Decision on individual basis