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Stommel AM, Herkner H, Kienbacher CL, Wildner B, Hermann A, Staudinger T. Effects of extracorporeal CO 2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis. Crit Care 2024; 28:146. [PMID: 38693569 PMCID: PMC11061932 DOI: 10.1186/s13054-024-04927-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/21/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure. METHODS We conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios. RESULTS A total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. "Higher extraction" systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R. CONCLUSIONS ECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. "Higher extraction" systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R's effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R. PROSPERO Registration No: CRD 42020154110 (on January 24, 2021).
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Affiliation(s)
- Alexandra-Maria Stommel
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Calvin Lukas Kienbacher
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Brigitte Wildner
- University Library, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Lai A, Omori N, Napolitano JE, Antaki JF, Cook KE. Effect of Artificial Lung Fiber Bundle Geometric Design on Micro- and Macro-scale Clot Formation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.05.574443. [PMID: 38260509 PMCID: PMC10802461 DOI: 10.1101/2024.01.05.574443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
The hollow fiber membrane bundle is the functional component of artificial lungs, transferring oxygen and carbon dioxide to and from the blood. It is also the primary location of blood clot formation and propagation in these devices. The geometric design of fiber bundles is defined by a narrow range of parameters that determine gas exchange efficiency and blood flow resistance, such as fiber packing density, path length, and frontal area. However, these parameters also affect thrombosis. This study investigated the effect of these parameters on clot formation using 3-D printed flow chambers that mimic the geometry and blood flow patterns of fiber bundles. Hollow fibers were represented by an array of vertical micro-rods (380 micron diameter) arranged with varying packing densities (40, 50, and 60%) and path lengths (2 and 4 cm). Blood was pumped through the device corresponding to three mean blood flow velocities (16, 20, and 25 cm/min). Results showed that (1) clot formation decreases dramatically with decreasing packing density and increasing blood flow velocity, (2) clot formation at the outlet of fiber bundle enhances deposition upstream, and consequently (3) greater path length provides more clot-free fiber surface area for gas exchange than a shorter path length. These results can be used to create less thrombogenic, more efficient artificial lung designs. Translational Impact Sentence Fiber bundle parameters, such as decreased packing density, increased blood flow velocity, and a longer path length, can be used to design a less thrombogenic, more efficient artificial lung to extend functionality.
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Tonetti T, Zanella A, Pérez-Torres D, Grasselli G, Ranieri VM. Current knowledge gaps in extracorporeal respiratory support. Intensive Care Med Exp 2023; 11:77. [PMID: 37962702 PMCID: PMC10645840 DOI: 10.1186/s40635-023-00563-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
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Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
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Kapoor PM, Oza P, Goyal V, Mehta Y, Kanchi M. Extracorporeal Membrane Oxygenation Carbon Dioxide Removal. JOURNAL OF CARDIAC CRITICAL CARE TSS 2023. [DOI: 10.25259/mm_jccc_304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Protective lung ventilation is the mainstay ventilation strategy for patients on extracorporeal membrane oxygenation (ECMO), as prolonged mechanical ventilation increases morbidity and mortality; the technicalities of ventilation with ECMO have evolved in the last decade. ECMO on the other end of the spectrum is a complete or total extracorporeal support, which supplies complete physiological blood gas exchanges, normally performed by the native lungs and thus is capable of delivering oxygen (O2) and removing CO equal to the metabolic needs of the patient, it requires higher flows, is more complex, and uses bigger cannulas, higher dose of heparin and higher blood volume for priming. This review describes in detail carbon dioxide removal on ECMO.
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Affiliation(s)
| | - Pranay Oza
- Department of ECMO, RVCC, Mumbai, Maharashtra, India,
| | - Venkat Goyal
- Department of ECMO, RVCC, Mumbai, Maharashtra, India,
| | - Yatin Mehta
- Department of ECMO, RVCC, Mumbai, Maharashtra, India,
| | - Muralidhar Kanchi
- Department of Anesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, Narayana Health City, Bommasandra, Karnataka, India,
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Stącel T, Sybila P, Mędrala A, Ochman M, Latos M, Zawadzki F, Pióro A, Pasek P, Przybyłowski P, Hrapkowicz T, Mroczek E, Kuczaj A, Kopeć G, Fiszer R, Pawlak S, Stanjek-Cichoracka A, Urlik M. Novel Hybrid Treatment for Pulmonary Arterial Hypertension with or without Eisenmenger Syndrome: Double Lung Transplantation with Simultaneous Endovascular or Classic Surgical Closure of the Patent Ductus Arteriosus (PDA). J Cardiovasc Dev Dis 2022; 9:jcdd9120457. [PMID: 36547454 PMCID: PMC9783473 DOI: 10.3390/jcdd9120457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Patients with pulmonary arterial hypertension (PAH) become candidates for lung or lung and heart transplantation when the maximum specific therapy is no longer effective. The most difficult challenge is choosing one of the above options in the event of symptoms of right ventricular failure. Here, we present two female patients with PAH: (1) a 21-year-old patient with Eisenmenger syndrome, caused by a congenital defect-patent ductus arteriosus (PDA); and (2) a 39-year-old patient with idiopathic PAH and coexistent PDA. Their common denominator is PDA and the hybrid surgery performed: double lung transplantation with simultaneous PDA closure. The operation was performed after pharmacological bridging (conditioning) to transplantation that lasted for 33 and 70 days, respectively. In both cases, PDA closure effectiveness was 100%. Both patients survived the operation (100%); however, patient no. 1 died on the 2nd postoperative day due to multi-organ failure; while patient no. 2 was discharged home in full health. The authors did not find a similar description of the operation in the available literature and PubMed database. Hence, we propose this new treatment method for its effectiveness and applicability proven in our practice.
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Affiliation(s)
- Tomasz Stącel
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
- Correspondence: (T.S.); (A.M.); Tel.: +48-691-045-785 (T.S.); +48-731-832-083 (A.M.)
| | - Paweł Sybila
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Agata Mędrala
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
- Correspondence: (T.S.); (A.M.); Tel.: +48-691-045-785 (T.S.); +48-731-832-083 (A.M.)
| | - Marek Ochman
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Magdalena Latos
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Fryderyk Zawadzki
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Anna Pióro
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac Anaesthesia and Intensive Care, Medical University of Silesia, 40-055 Katowice, Poland
| | - Piotr Pasek
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
- First Department of General Surgery, Collegium Medicum of Jagiellonian University, 30-688 Krakow, Poland
| | - Tomasz Hrapkowicz
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Ewa Mroczek
- Institute of Heart Diseases, University Clinical Hospital Mikulicz Radecki in Wroclaw, ul. Borowska 213, 50-558 Wroclaw, Poland
| | - Agnieszka Kuczaj
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Grzegorz Kopeć
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland
| | - Roland Fiszer
- Silesian Centre for Heart Diseases in Zabrze, Department of Congenital Heart Defects and Pediatric Cardiology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Szymon Pawlak
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Anita Stanjek-Cichoracka
- Department of Biophysics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Jedności 8, 41-200 Sosnowiec, Poland
| | - Maciej Urlik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery, and Transplantology, Medical University of Silesia, 40-055 Katowice, Poland
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Kapoor PM. Extracorporeal Membrane Oxygenation for Lung Transplantation. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1757364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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7
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Worku E, Brodie D, Ling RR, Ramanathan K, Combes A, Shekar K. Venovenous extracorporeal CO 2 removal to support ultraprotective ventilation in moderate-severe acute respiratory distress syndrome: A systematic review and meta-analysis of the literature. Perfusion 2022:2676591221096225. [PMID: 35656595 DOI: 10.1177/02676591221096225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO2R in supporting ultra-protective ventilation in moderate-to-severe ARDS. METHODS MEDLINE and EMBASE were interrogated for studies (2000-2021) reporting venovenous ECCO2R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO2R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO2R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. RESULTS Ten studies reporting 421 patients (PaO2:FiO2 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH2O reduction (95%-CI: 3.22-3.91) in driving pressure from baseline (p < .001) and a 1.89 mL/kg (95%-CI: 1.75-2.02, p < .001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO2:FiO2 ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. CONCLUSIONS Venovenous ECCO2R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made.
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Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, 12294Columbia University College of Physicians and Surgeons, NY, USA
- Center for Acute Respiratory Failure, 25065New York-Presbyterian Hospital, NY, USA
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiothoracic Intensive Care Unit, 375583National University Heart Centre, National University Hospital, Singapore
| | - Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, 26933Pitié-Salpêtrière Hospital, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane and Bond University, Gold Coast, QLD, Australia
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Hwalek A, Rosenheck JP, Whitson BA. Lung transplantation for pulmonary hypertension. J Thorac Dis 2022; 13:6708-6716. [PMID: 34992846 PMCID: PMC8662488 DOI: 10.21037/jtd-2021-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/14/2021] [Indexed: 11/06/2022]
Abstract
From its identification as a distinct disease entity, understanding and management of pulmonary hypertension has continuously evolved. Diagnostic and therapeutic interventions have greatly improved the prognostic implications of this devastating disease, previously rapidly and uniformly fatal to one chronically managed by multi-disciplinary teams. Improved diagnostic algorithms and active research into biochemical signatures of pulmonary hypertension (PH) have led to earlier diagnosis of PH. Medical therapy has moved from upfront use of continuous intravenous prostaglandins to administration of combinations of oral medications targeting multiple pathways underlying this disease process. In addition to improved medical therapies, recently introduced interventions such as pulmonary endarterectomy and pulmonary artery balloon angioplasty for chronic thromboembolic pulmonary hypertension (CTEPH) give patients an increasing array of treatment options. Despite these many advances, lung transplantation remains the definitive treatment for patients with disease refractory to or progressing on best medical therapy. As our understanding of medical therapy has advanced, so to have best practices for lung transplantation. Recipient selection and approach to organ transplantation techniques have continuously evolved. Mechanical circulatory support has become increasingly employed to bridge patients through lung transplantation in the immediate post transplantation recovery. In this review, we give a history of lung transplantation for PH, an overview of PH, discuss current best practices and look to the future for insights into the care of these patients.
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Affiliation(s)
- Ann Hwalek
- Division of Cardiac Surgery, Columbus, Department of Surgery, The Ohio State University Wexner Medical Center, OH, USA
| | - Justin P Rosenheck
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A Whitson
- Division of Cardiac Surgery, Columbus, Department of Surgery, The Ohio State University Wexner Medical Center, OH, USA
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Yu TZ, Tatum RT, Saxena A, Ahmad D, Yost CC, Maynes EJ, O'Malley TJ, Massey HT, Swol J, Whitson BA, Tchantchaleishvili V. Utilization and outcomes of extracorporeal CO 2 removal (ECCO 2 R): Systematic review and meta-analysis of arterio-venous and veno-venous ECCO 2 R approaches. Artif Organs 2021; 46:763-774. [PMID: 34897748 DOI: 10.1111/aor.14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/25/2021] [Accepted: 11/09/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Extracorporeal carbon dioxide removal (ECCO2 R) provides respiratory support to patients suffering from hypercapnic respiratory failure by utilizing an extracorporeal shunt and gas exchange membrane to remove CO2 from either the venous (VV-ECCO2 R) or arterial (AV-ECCO2 R) system before return into the venous site. AV-ECCO2 R relies on the patient's native cardiac function to generate pressures needed to deliver blood through the extracorporeal circuit. VV-ECCO2 R utilizes a mechanical pump and can be used to treat patients with inadequate native cardiac function. We sought to evaluate the existing evidence comparing the subgroups of patients supported on VV and AV-ECCO2 R devices. METHODS A literature search was performed to identify all relevant studies published between 2000 and 2019. Demographic information, medical indications, perioperative variables, and clinical outcomes were extracted for systematic review and meta-analysis. RESULTS Twenty-five studies including 826 patients were reviewed. 60% of patients (497/826) were supported on VV-ECCO2 R. The most frequent indications were acute respiratory distress syndrome (ARDS) [69%, (95%CI: 53%-82%)] and chronic obstructive pulmonary disease (COPD) [49%, (95%CI: 37%-60%)]. ICU length of stay was significantly shorter in patients supported on VV-ECCO2 R compared to AV-ECCO2 R [15 (95%CI: 7-23) vs. 42 (95%CI: 17-67) days, p = 0.05]. In-hospital mortality was not significantly different [27% (95%CI: 18%-38%) vs. 36% (95%CI: 24%-51%), p = 0.26]. CONCLUSION Both VV and AV-ECCO2 R provided clinically meaningful CO2 removal with comparable mortality.
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Affiliation(s)
- Tiffany Z Yu
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert T Tatum
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Abhiraj Saxena
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Danial Ahmad
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin C Yost
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth J Maynes
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas J O'Malley
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard T Massey
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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10
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Faccioli E, Terzi S, Pangoni A, Lomangino I, Rossi S, Lloret A, Cannone G, Marino C, Catelli C, Dell'Amore A. Extracorporeal membrane oxygenation in lung transplantation: Indications, techniques and results. World J Transplant 2021; 11:290-302. [PMID: 34316453 PMCID: PMC8290996 DOI: 10.5500/wjt.v11.i7.290] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/13/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in the field of lung transplantation has rapidly expanded over the past 30 years. It has become an important tool in an increasing number of specialized centers as a bridge to transplantation and in the intra-operative and/or post-operative setting. ECMO is an extremely versatile tool in the field of lung transplantation as it can be used and adapted in different configurations with several potential cannulation sites according to the specific need of the recipient. For example, patients who need to be bridged to lung transplantation often have hypercapnic respiratory failure that may preferably benefit from veno-venous (VV) ECMO or peripheral veno-arterial (VA) ECMO in the case of hemodynamic instability. Moreover, in an intra-operative setting, VV ECMO can be maintained or switched to a VA ECMO. The routine use of intra-operative ECMO and its eventual prolongation in the post-operative period has been widely investigated in recent years by several important lung transplantation centers in order to assess the graft function and its potential protective role on primary graft dysfunction and on ischemia-reperfusion injury. This review will assess the current evidence on the role of ECMO in the different phases of lung transplantation, while analyzing different studies on pre, intra- and post-operative utilization of this extracorporeal support.
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Affiliation(s)
- Eleonora Faccioli
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Stefano Terzi
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Alessandro Pangoni
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Ivan Lomangino
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Sara Rossi
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Andrea Lloret
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Giorgio Cannone
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Carlotta Marino
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Chiara Catelli
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Andrea Dell'Amore
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
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Syed A, Kerdi S, Qamar A. Bioengineering Progress in Lung Assist Devices. Bioengineering (Basel) 2021; 8:89. [PMID: 34203316 PMCID: PMC8301204 DOI: 10.3390/bioengineering8070089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/31/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
Artificial lung technology is advancing at a startling rate raising hopes that it would better serve the needs of those requiring respiratory support. Whether to assist the healing of an injured lung, support patients to lung transplantation, or to entirely replace native lung function, safe and effective artificial lungs are sought. After 200 years of bioengineering progress, artificial lungs are closer than ever before to meet this demand which has risen exponentially due to the COVID-19 crisis. In this review, the critical advances in the historical development of artificial lungs are detailed. The current state of affairs regarding extracorporeal membrane oxygenation, intravascular lung assists, pump-less extracorporeal lung assists, total artificial lungs, and microfluidic oxygenators are outlined.
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Affiliation(s)
- Ahad Syed
- Nanofabrication Core Lab, King Abdullah University of Science and Technology, Thuwal 23955-6900, Saudi Arabia;
| | - Sarah Kerdi
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal 23955-6900, Saudi Arabia;
| | - Adnan Qamar
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal 23955-6900, Saudi Arabia;
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12
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Abstract
PURPOSE OF REVIEW Need for intensive care in the patient with pulmonary arterial hypertension is associated with high mortality. This review will provide an overview of causes of ICU admission for patients with pulmonary hypertension and provide guidance on management. RECENT FINDINGS There is a paucity of evidence-based medical literature on management of patients with pulmonary arterial hypertension. This article will summarize the available literature and expert guidance on the topic. Patients with pulmonary arterial hypertension may require ICU care as a direct consequence of decompensated right heart failure. Alternatively, patients with pulmonary arterial hypertension may be affected by the myriad of maladies encountered every day in the ICU including acute respiratory failure, septic shock, and gastrointestinal bleeding. The treatment plan should focus on identifying and treating the cause for decompensation. In addition, optimization of right ventricular preload, reduction of right ventricular afterload, correction of hypotension and augmentation of right ventricular inotropy should be considered. SUMMARY The approach to ICU care of patients with pulmonary arterial hypertension requires special consideration with regard to intubation and mechanical ventilation and management of volume status and hemodynamics. Whenever possible, these patients should be transferred to centers with experience in treating this complex, vulnerable population.
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13
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Nasir BS, Klapper J, Hartwig M. Lung Transplant from ECMO: Current Results and Predictors of Post-transplant Mortality. CURRENT TRANSPLANTATION REPORTS 2021; 8:140-150. [PMID: 33842193 PMCID: PMC8021937 DOI: 10.1007/s40472-021-00323-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/22/2023]
Abstract
Purpose of Review We examined data from the last 5 years describing extracorporeal life support (ECLS) as a bridge to lung transplantation. We assessed predictors of survival to transplantation and post-transplant mortality. Recent Findings The number of lung transplants performed worldwide is increasing. This is accompanied by an increase in the type of patients being transplanted, including sicker patients with more advanced disease. Consequently, there is an increase in the need for bridging strategies, with varying success. Several predictors of failure have been identified. Major risk factors include retransplantation, other organ dysfunction, and deconditioning. Summary ECLS is a risky strategy but necessary for patients who would otherwise die if not bridged to transplantation. The presence of predictors for failure is not a contraindication for bridging. However, major risk factors should be approached cautiously. Other, more minor risk factors may be considered acceptable. More importantly, the strategy should be individualized for each patient to achieve the best possible outcomes.
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Affiliation(s)
- Basil S Nasir
- Division of Thoracic Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, 1000 rue Saint-Denis, Montreal, Quebec, H2X 0C1 Canada
| | - Jacob Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Medical Center, Durham, NC USA
| | - Matthew Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Medical Center, Durham, NC USA
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14
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Naito N, Ukita R, Wilbs J, Wu K, Lin X, Carleton NM, Roberts K, Jiang S, Heinis C, Cook KE. Combination of polycarboxybetaine coating and factor XII inhibitor reduces clot formation while preserving normal tissue coagulation during extracorporeal life support. Biomaterials 2021; 272:120778. [PMID: 33812214 DOI: 10.1016/j.biomaterials.2021.120778] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/16/2021] [Accepted: 03/20/2021] [Indexed: 12/17/2022]
Abstract
Blood contact with high surface area medical devices, such as dialysis and extracorporeal life support (ECLS), induces rapid surface coagulation. Systemic anticoagulation, such as heparin, is thus necessary to slow clot formation, but some patients suffer from bleeding complications. Both problems might be reduced by 1) replacing heparin anticoagulation with artificial surface inhibition of the protein adsorption that initiates coagulation and 2) selective inhibition of the intrinsic branch of the coagulation cascade. This approach was evaluated by comparing clot formation and bleeding times during short-term ECLS using zwitterionic polycarboxybetaine (PCB) surface coatings combined with either a potent, selective, bicyclic peptide inhibitor of activated Factor XII (FXII900) or standard heparin anticoagulation. Rabbits underwent venovenous ECLS with small sham oxygenators for 60 min using three means of anticoagulation (n = 4 ea): (1) PCB coating + FXII900 infusion, (2) PCB coating + heparin infusion with an activated clotting time of 220-300s, and (3) heparin infusion alone. Sham oxygenator blood clot weights in the PCB + FXII900 and PCB + heparin groups were 4% and 25% of that in the heparin group (p < 10-6 and p < 10-5), respectively. At the same time, the bleeding time remained normal in the PCB + FXII900 group (2.4 ± 0.2 min) but increased to 4.8 ± 0.5 and 5.1 ± 0.7 min in the PCB + heparin and heparin alone groups (p < 10-4 and 0.01). Sham oxygenator blood flow resistance was significantly lower in the PCB + FXII900 and PCB + heparin groups than in the heparin only group (p < 10-6 and 10-5). These results were confirmed by gross and scanning electron microscopy (SEM) images and fibrinopeptide A (FPA) concentrations. Thus, the combined use of PCB coating and FXII900 markedly reduced sham oxygenator coagulation and tissue bleeding times versus the clinical standard of heparin anticoagulation and is a promising anticoagulation method for clinical ECLS.
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Affiliation(s)
- Noritsugu Naito
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Rei Ukita
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Jonas Wilbs
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Kan Wu
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Xiaojie Lin
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Neil M Carleton
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Kalliope Roberts
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Shaoyi Jiang
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Christian Heinis
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA.
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15
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Dipresa D, Kalozoumis P, Pflaum M, Peredo A, Wiegmann B, Haverich A, Korossis S. Hemodynamic Assessment of Hollow-Fiber Membrane Oxygenators Using Computational Fluid Dynamics in Heterogeneous Membrane Models. J Biomech Eng 2021; 143:1096598. [DOI: 10.1115/1.4049808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Indexed: 11/08/2022]
Abstract
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used clinically for more than 40 years as a bridge to transplantation, with hollow-fiber membrane (HFM) oxygenators gaining in popularity due to their high gas transfer and low flow resistance. In spite of the technological advances in ECMO devices, the inevitable contact of the perfused blood with the polymer hollow-fiber gas-exchange membrane, and the subsequent thrombus formation, limits their clinical usage to only 2–4 weeks. In addition, the inhomogeneous flow in the device can further enhance thrombus formation and limit gas-transport efficiency. Endothelialization of the blood contacting surfaces of ECMO devices offers a potential solution to their inherent thrombogenicity. However, abnormal shear stresses and inhomogeneous blood flow might affect the function and activation status of the seeded endothelial cells (ECs). In this study, the blood flow through two HFM oxygenators, including the commercially available iLA® MiniLung Petite Novalung (Xenios AG, Germany) and an experimental one for the rat animal model, was modeled using computational fluid dynamics (CFD), with a view to assessing the magnitude and distribution of the wall shear stress (WSS) on the hollow fibers and flow fields in the oxygenators. This work demonstrated significant inhomogeneity in the flow dynamics of both oxygenators, with regions of high hollow-fiber WSS and regions of stagnant flow, implying a variable flow-induced stimulation on seeded ECs and possible EC activation and damage in a biohybrid oxygenator setting.
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Affiliation(s)
- Daniele Dipresa
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Panagiotis Kalozoumis
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Michael Pflaum
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Ariana Peredo
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany
| | - Bettina Wiegmann
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany; German Centre for Lung Research (DZL), BREATH, Hannover Medical School, Hannover 30625, Germany
| | - Axel Haverich
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany; German Centre for Lung Research (DZL), BREATH, Hannover Medical School, Hannover 30625, Germany
| | - Sotirios Korossis
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Hannover 30625, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover 30625, Germany; German Centre for Lung Research (DZL), BREATH, Hannover Medical School, Hannover 30625, Germany; Cardiopulmonary Regenerative Engineeri
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16
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Blauvelt DG, Abada EN, Oishi P, Roy S. Advances in extracorporeal membrane oxygenator design for artificial placenta technology. Artif Organs 2021; 45:205-221. [PMID: 32979857 PMCID: PMC8513573 DOI: 10.1111/aor.13827] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/28/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
Extreme prematurity, defined as a gestational age of fewer than 28 weeks, is a significant health problem worldwide. It carries a high burden of mortality and morbidity, in large part due to the immaturity of the lungs at this stage of development. The standard of care for these patients includes support with mechanical ventilation, which exacerbates lung pathology. Extracorporeal life support (ECLS), also called artificial placenta technology when applied to extremely preterm (EPT) infants, offers an intriguing solution. ECLS involves providing gas exchange via an extracorporeal device, thereby doing the work of the lungs and allowing them to develop without being subjected to injurious mechanical ventilation. While ECLS has been successfully used in respiratory failure in full-term neonates, children, and adults, it has not been applied effectively to the EPT patient population. In this review, we discuss the unique aspects of EPT infants and the challenges of applying ECLS to these patients. In addition, we review recent progress in artificial placenta technology development. We then offer analysis on design considerations for successful engineering of a membrane oxygenator for an artificial placenta circuit. Finally, we examine next-generation oxygenators that might advance the development of artificial placenta devices.
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Affiliation(s)
- David G. Blauvelt
- Department of Pediatrics, University of California, San Francisco, California
| | - Emily N. Abada
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California
| | - Peter Oishi
- Department of Pediatrics, University of California, San Francisco, California
| | - Shuvo Roy
- Department of Pediatrics, University of California, San Francisco, California
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17
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Veno-Venous Extracorporeal Lung Support as a Bridge to or Through Lung Volume Reduction Surgery in Patients with Severe Hypercapnia. ASAIO J 2021; 66:952-959. [PMID: 32740358 DOI: 10.1097/mat.0000000000001108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.
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18
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Redwan B, Freermann C, Akil A, Fischer S. [Extracorporeal Lung Support in Thoracic Surgery: Basics and Pathophysiology]. Pneumologie 2021; 75:60-66. [PMID: 33461235 DOI: 10.1055/a-1172-7202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Extracorporeal lung support (ECLS) is of increasing importance in general thoracic surgery. Different modes of ECLS may be applied in several situations throughout the perioperative phase and are adapted to the individual patient's needs and the planned surgical procedures. ECLS is not a static procedure and should be always evaluated according to the present condition of the patient. Therefore, it is essential to understand the pathophysiology of the disease and the different ECLS modes, as well as the different cannulation options, in order to be able to use the different escalation and de-escalation techniques in accordance with the clinical situation.
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Affiliation(s)
- B Redwan
- Sektion für Thoraxchirurgie, Universitätsklinik Münster, Deutschland
| | - C Freermann
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Deutschland
| | - A Akil
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Deutschland
| | - S Fischer
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Deutschland
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19
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Hascoet S, Boet A, Roussin R, Guihaire J, Savale L, Mercier O, Fadel E. Pumpless Lung Assist as a Bridge to Medical Therapy in a Teenager With Pulmonary Arterial Hypertension and Partial Anomalous Pulmonary Venous Return. Can J Cardiol 2020; 36:1831.e7-1831.e9. [PMID: 32512141 DOI: 10.1016/j.cjca.2020.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 11/17/2022] Open
Abstract
Heart failure is the main cause of death in patients with pulmonary arterial hypertension and congenital heart disease. We used an original approach in a 15-year-old girl with rapidly progressive right heart failure secondary to severe pulmonary arterial hypertension and partial anomalous pulmonary venous return. After surgical congenital heart defect repair on cardiopulmonary bypass, she was weaned off bypass using a central Novalung for 11 days, then started on triple specific pulmonary vasodilator therapy.
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Affiliation(s)
- Sébastien Hascoet
- Department of Congenital Heart Diseases, Centre Constitutif Malformations Cardiaques Congénitales Complexes M3C, Groupe Hospitalier Paris Saint-Joseph, Hôpital Marie Lannelongue, Plessis-Robinson, UMR-S 999, Inserm, Faculté de Médecine Paris-Saclay, Paris-Saclay University, France.
| | - Angèle Boet
- Department of Congenital Heart Diseases, Centre Constitutif Malformations Cardiaques Congénitales Complexes M3C, Groupe Hospitalier Paris Saint-Joseph, Hôpital Marie Lannelongue, Plessis-Robinson, UMR-S 999, Inserm, Faculté de Médecine Paris-Saclay, Paris-Saclay University, France
| | - Régine Roussin
- Department of Congenital Heart Diseases, Centre Constitutif Malformations Cardiaques Congénitales Complexes M3C, Groupe Hospitalier Paris Saint-Joseph, Hôpital Marie Lannelongue, Plessis-Robinson, UMR-S 999, Inserm, Faculté de Médecine Paris-Saclay, Paris-Saclay University, France
| | - Julien Guihaire
- Departments of Cardiac, Thoracic, and Vascular surgery, Centre de Référence de l'Hypertension Artérielle Pulmonaire Sévère, Groupe Hospitalier Paris Saint-Joseph, Hôpital Marie Lannelongue, Plessis-Robinson, Faculté de Médecine Paris-Saclay, Paris-Saclay University, France, UMR-S 999, Inserm, France
| | - Laurent Savale
- Department of Pneumology, Centre de Référence de l'Hypertension Pulmonaire Sévère, DHU Thorax Innovation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France UMR-S 999, Inserm, Hôpital Marie Lannelongue, Faculté de Médecine Paris-Saclay, Université Paris-Saclay, France
| | - Olaf Mercier
- Departments of Cardiac, Thoracic, and Vascular surgery, Centre de Référence de l'Hypertension Artérielle Pulmonaire Sévère, Groupe Hospitalier Paris Saint-Joseph, Hôpital Marie Lannelongue, Plessis-Robinson, Faculté de Médecine Paris-Saclay, Paris-Saclay University, France, UMR-S 999, Inserm, France
| | - Elie Fadel
- Departments of Cardiac, Thoracic, and Vascular surgery, Centre de Référence de l'Hypertension Artérielle Pulmonaire Sévère, Groupe Hospitalier Paris Saint-Joseph, Hôpital Marie Lannelongue, Plessis-Robinson, Faculté de Médecine Paris-Saclay, Paris-Saclay University, France, UMR-S 999, Inserm, France
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20
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Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion 2020; 35:492-508. [PMID: 32156179 DOI: 10.1177/0267659120906048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TECHNOLOGY Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. INDICATIONS Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called "protective" level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. COMPLICATIONS Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called "high-extraction systems" working with higher blood flows and larger membranes may be more effective with respect to clinical goals.
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Affiliation(s)
- Thomas Staudinger
- Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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21
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Francis L, Whitener S, McKinnon J, Whitener G. Pulmonary Hypertension and Thoracic Surgery: Impact and Treatment Options. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00360-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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22
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Comber EM, Palchesko RN, Ng WH, Ren X, Cook KE. De novo lung biofabrication: clinical need, construction methods, and design strategy. Transl Res 2019; 211:1-18. [PMID: 31103468 DOI: 10.1016/j.trsl.2019.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/10/2019] [Accepted: 04/25/2019] [Indexed: 01/22/2023]
Abstract
Chronic lung disease is the 4th leading cause of death in the United States. Due to a shortage of donor lungs, alternative approaches to support failing, native lungs have been attempted, including mechanical ventilation and various forms of artificial lungs. However, each of these support methods causes significant complications when used for longer than a few days and are thus not capable of long-term support. For artificial lungs, complications arise due to interactions between the artificial materials of the device and the blood of the recipient. A potential new approach is the fabrication of lungs from biological materials, such that the gas exchange membranes provide a more biomimetic blood-contacting interface. Recent advancements with three-dimensional, soft-tissue biofabrication methods and the engineering of thin, basement membranes demonstrate the potential of fabricating a lung scaffold from extracellular matrix materials. This scaffold could then be seeded with endothelial and epithelial cells, matured within a bioreactor, and transplanted. In theory, this fully biological lung could provide improved, long-term biocompatibility relative to artificial lungs, but significant work is needed to perfect the organ design and construction methods. Like artificial lungs, biofabricated lungs do not need to follow the shape and structure of a native lung, allowing for simpler manufacture. However, various functional requirements must still be met, including stable, efficient gas exchange for a period of years. Design decisions depend on the disease state, how the organ is implanted, and the latest biofabrication methods available in a rapidly evolving field.
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Affiliation(s)
- Erica M Comber
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania.
| | - Rachelle N Palchesko
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Wai Hoe Ng
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Xi Ren
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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23
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Ukita R, Wu K, Lin X, Carleton NM, Naito N, Lai A, Do-Nguyen CC, Demarest CT, Jiang S, Cook KE. Zwitterionic poly-carboxybetaine coating reduces artificial lung thrombosis in sheep and rabbits. Acta Biomater 2019; 92:71-81. [PMID: 31082571 PMCID: PMC6633914 DOI: 10.1016/j.actbio.2019.05.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/30/2019] [Accepted: 05/07/2019] [Indexed: 12/24/2022]
Abstract
Current artificial lungs fail in 1-4 weeks due to surface-induced thrombosis. Biomaterial coatings may be applied to anticoagulate artificial surfaces, but none have shown marked long-term effectiveness. Poly-carboxybetaine (pCB) coatings have shown promising results in reducing protein and platelet-fouling in vitro. However, in vivo hemocompatibility remains to be investigated. Thus, three different pCB-grafting approaches to artificial lung surfaces were first investigated: 1) graft-to approach using 3,4-dihydroxyphenylalanine (DOPA) conjugated with pCB (DOPA-pCB); 2) graft-from approach using the Activators ReGenerated by Electron Transfer method of atom transfer radical polymerization (ARGET-ATRP); and 3) graft-to approach using pCB randomly copolymerized with hydrophobic moieties. One device coated with each of these methods and one uncoated device were attached in parallel within a veno-venous sheep extracorporeal circuit with no continuous anticoagulation (N = 5 circuits). The DOPA-pCB approach showed the least increase in blood flow resistance and the lowest incidence of device failure over 36-hours. Next, we further investigated the impact of tip-to-tip DOPA-pCB coating in a 4-hour rabbit study with veno-venous micro-artificial lung circuit at a higher activated clotting time of 220-300 s (N ≥ 5). Here, DOPA-pCB reduced fibrin formation (p = 0.06) and gross thrombus formation by 59% (p < 0.05). Therefore, DOPA-pCB is a promising material for improving the anticoagulation of artificial lungs. STATEMENT OF SIGNIFICANCE: Chronic lung diseases lead to 168,000 deaths each year in America, but only 2300 lung transplantations happen each year. Hollow fiber membrane oxygenators are clinically used as artificial lungs to provide respiratory support for patients, but their long-term viability is hindered by surface-induced clot formation that leads to premature device failure. Among different coatings investigated for blood-contacting applications, poly-carboxybetaine (pCB) coatings have shown remarkable reduction in protein adsorption in vitro. However, their efficacy in vivo remains unclear. This is the first work that investigates various pCB-coating methods on artificial lung surfaces and their biocompatibility in sheep and rabbit studies. This work highlights the promise of applying pCB coatings on artificial lungs to extend its durability and enable long-term respiratory support for lung disease patients.
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Affiliation(s)
- Rei Ukita
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA.
| | - Kan Wu
- Department of Chemical Engineering, University of Washington, Box 351750, Seattle, WA 98195-1750, USA
| | - Xiaojie Lin
- Department of Chemical Engineering, University of Washington, Box 351750, Seattle, WA 98195-1750, USA
| | - Neil M Carleton
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Noritsugu Naito
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Angela Lai
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Chi Chi Do-Nguyen
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Caitlin T Demarest
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Shaoyi Jiang
- Department of Chemical Engineering, University of Washington, Box 351750, Seattle, WA 98195-1750, USA
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
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72-Hour in vivo evaluation of nitric oxide generating artificial lung gas exchange fibers in sheep. Acta Biomater 2019; 90:122-131. [PMID: 30953800 DOI: 10.1016/j.actbio.2019.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 12/21/2022]
Abstract
The large, densely packed artificial surface area of artificial lungs results in rapid clotting and device failure. Surface generated nitric oxide (NO) can be used to reduce platelet activation and coagulation on gas exchange fibers, while not inducing patient bleeding due to its short half-life in blood. To generate NO, artificial lungs can be manufactured with PDMS hollow fibers embedded with copper nanoparticles (Cu NP) and supplied with an infusion of the NO donor S-nitroso-N-acetyl-penicillamine (SNAP). The SNAP reacts with Cu NP to generate NO. This study investigates clot formation and gas exchange performance of artificial lungs with either NO-generating Cu-PDMS or standard polymethylpentene (PMP) fibers. One miniature artificial lung (MAL) made with 10 wt% Cu-PDMS hollow fibers and one PMP control MAL were attached to sheep in parallel in a veno-venous extracorporeal membrane oxygenation circuit (n = 8). Blood flow through each device was set at 300 mL/min, and each device received a SNAP infusion of 0.12 μmol/min. The ACT was between 110 and 180 s in all cases. Blood flow resistance was calculated as a measure of clot formation on the fiber bundle. Gas exchange experiments comparing the two groups were conducted every 24 h at blood flow rates of 300 and 600 mL/min. Devices were removed once the resistance reached 3x baseline (failure) or following 72 h. All devices were imaged using scanning electron microscopy (SEM) at the inlet, outlet, and middle of the fiber bundle. The Cu-PDMS NO generating MALs had a significantly smaller increase in resistance compared to the control devices. Resistance rose from 26 ± 8 and 23 ± 5 in the control and Cu-PDMS devices, respectively, to 35 ± 8 mmHg/(mL/min) and 72 ± 23 mmHg/(mL/min) at the end of each experiment. The resistance and SEM imaging of fiber surfaces demonstrate lower clot formation on Cu-PDMS fibers. Although not statistically significant, oxygen transfer for the Cu-PDMS MALs was 13.3% less than the control at 600 mL/min blood flow rate. Future in vivo studies with larger Cu-PDMS devices are needed to define gas exchange capabilities and anticoagulant activity over a long-term study at clinically relevant ACTs. STATEMENT OF SIGNIFICANCE: In artificial lungs, the large, densely-packed blood contacting surface area of the hollow fiber bundle is critical for gas exchange but also creates rapid, surface-generated clot requiring significant anticoagulation. Monitoring of anticoagulation, thrombosis, and resultant complications has kept permanent respiratory support from becoming a clinical reality. In this study, we use a hollow fiber material that generates nitric oxide (NO) to prevent platelet activation at the blood contacting surface. This material is tested in vivo in a miniature artificial lung and compared against the clinical standard. Results indicated significantly reduced clot formation. Surface-focused anticoagulation like this should reduce complication rates and allow for permanent respiratory support by extending the functional lifespan of artificial lungs and can further be applied to other medical devices.
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Abstract
BACKGROUND Lung transplantation (LTPL) is considered as a salvage therapeutic option in patients with end-stage lung disease. However, there is a lack of sufficient data on the use of LTPL in patients with acute respiratory distress syndrome (ARDS). Although there are few case reports on lung transplant for ARDS, no case series exists up to date. The aim of this study was to evaluate the clinical outcomes of patients with ARDS in accordance with the LTPL status. METHODS Patients who had severe ARDS (PaO2/FiO2 ratio ≤ 100 mm Hg with positive end-expiratory pressure ≥ 5 cm H2O) and were listed for LTPL with no underlying end-stage lung disease were included in this single-center retrospective study. Demographic and clinical data of the patients were collected and analyzed. RESULTS Fourteen patients were listed for LTPL due to severe ARDS. All patients received mechanical ventilation, and 12 (86%) patients underwent extracorporeal membrane oxygenation. Of the 9 patients who underwent LTPL, 8 (89%) survived, whereas only 1 (20%) patient out of those who did not receive LTPL survived. The median survival time of the patients who underwent LTPL was 1996 days (interquartile range [IQR], 872-2239), compared with 49 days (IQR, 872-2239) in patients who did not undergo LTPL. The median survival time after LTPL was 64 months (IQR, 28-72). The 3-year survival rate of the recipients was 78%. CONCLUSIONS LTPL may be considered as a therapeutic option in a select group of patients with severe ARDS. However, the irreversibility of the patient's lung status should be considered.
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Zwirner U, Höffler K, Pflaum M, Korossis S, Haverich A, Wiegmann B. Identifying an optimal seeding protocol and endothelial cell substrate for biohybrid lung development. J Tissue Eng Regen Med 2018; 12:2319-2330. [DOI: 10.1002/term.2764] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 07/17/2018] [Accepted: 10/18/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Ulrich Zwirner
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School Hannover Germany
- REBIRTH ‐ Cluster of ExcellenceHannover Medical School Hannover Germany
| | - Klaus Höffler
- Department for Cardiothoracic, Transplantation and Vascular SurgeryHannover Medical School Hannover Germany
| | - Michael Pflaum
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School Hannover Germany
- REBIRTH ‐ Cluster of ExcellenceHannover Medical School Hannover Germany
| | - Sotirios Korossis
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School Hannover Germany
| | - Axel Haverich
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School Hannover Germany
- REBIRTH ‐ Cluster of ExcellenceHannover Medical School Hannover Germany
- Department for Cardiothoracic, Transplantation and Vascular SurgeryHannover Medical School Hannover Germany
- German Centre for Lung Research (DZL) Hannover Germany
| | - Bettina Wiegmann
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School Hannover Germany
- REBIRTH ‐ Cluster of ExcellenceHannover Medical School Hannover Germany
- Department for Cardiothoracic, Transplantation and Vascular SurgeryHannover Medical School Hannover Germany
- German Centre for Lung Research (DZL) Hannover Germany
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Artificial Lungs for Lung Failure. J Am Coll Cardiol 2018; 72:1640-1652. [DOI: 10.1016/j.jacc.2018.07.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/13/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022]
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Ius F, Tudorache I, Warnecke G. Extracorporeal support, during and after lung transplantation: the history of an idea. J Thorac Dis 2018; 10:5131-5148. [PMID: 30233890 DOI: 10.21037/jtd.2018.07.43] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
During recent years, continuous technological innovation has provoked an increase of extracorporeal life support (ECLS) use for perioperative cardiopulmonary support in lung transplantation. Initial results were disappointing, due to ECLS-specific complications and high surgical risk of the supported patients. However, the combination of improved patient management, multidisciplinary team work and standardization of ECLS protocols has recently yielded excellent results in several case series from high-volume transplant centres. Therein, it was demonstrated that, although the prevalence of complications remains higher in supported patients, there may be no difference in long-term graft function between supported and non-supported patients. These results are important, because most of the patients who require ECLS support in lung transplantation are young and have no other chance to survive, but to be transplanted. Moreover, there is no device for "bridging to destination" therapy in lung transplantation. Of note, the evidence in favour of ECLS support in lung transplantation was never validated by randomized controlled trials, but by everyday experience at the patient bed-side. Here, we review the state-of-the-art ECLS evidence for intraoperative and postoperative cardiopulmonary support in lung transplantation.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
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Staudinger T. [Extracorporeal membrane oxygenation : System selection, (contra)indications, and management]. Med Klin Intensivmed Notfmed 2018; 112:295-302. [PMID: 28432405 DOI: 10.1007/s00063-017-0279-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
There are a large number of extracorporeal membrane oxygenation (ECMO) systems and configurations. Thorough planning and evaluation of specific therapeutic needs are necessary to tailor ECMO therapy to the individual patient situation. Indications tend towards lowering the threshold towards respiratory ECMO. Patients with severe acute respiratory distress syndrome (ARDS) not improving to optimization of ventilation and supportive therapeutic measures potentially qualify for ECMO. Contraindications are relative and have to be considered in the light of the individual risk-benefit ratio. The same is true for decisions to stop ECMO therapy in case of futility for which reliable evidence does not exist.
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Affiliation(s)
- T Staudinger
- Universitätsklinik für Innere Medizin I, Intensivstation 13.i2, Allgemeines Krankenhaus der Stadt Wien/Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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McRae K, de Perrot M. Principles and indications of extracorporeal life support in general thoracic surgery. J Thorac Dis 2018; 10:S931-S946. [PMID: 29744220 DOI: 10.21037/jtd.2018.03.116] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The role of extracorporeal life support (ECLS) has expanded rapidly over the past 15 years to become an important tool in advanced general thoracic surgery practice. Intra-operative and in some cases continued post-operative ECLS is redefining the scope of complex surgical care. ECLS encompasses a spectrum of temporary mechanical support that may remove CO2, oxygenate or provide hemodynamic support or a combination thereof. The most common modalities used in general thoracic surgery include extracorporeal membrane oxygenation (ECMO), interventional lung assist device (iLA® Novalung®, Heilbronn, Germany), and extracorporeal CO2 removal (ECCO2R). The ECMO and Novalung® devices can be used in different modes for the short term or long-term support depending on the situation. In this review, the principles and current applications of ECLS in general thoracic surgery are presented.
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Affiliation(s)
- Karen McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Canada
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Shigemura N. Extracorporeal lung support for advanced lung failure: a new era in thoracic surgery and translational science. Gen Thorac Cardiovasc Surg 2017; 66:130-136. [DOI: 10.1007/s11748-017-0880-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/10/2017] [Indexed: 01/25/2023]
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Hoetzenecker K, Donahoe L, Yeung JC, Azad S, Fan E, Ferguson ND, Del Sorbo L, de Perrot M, Pierre A, Yasufuku K, Singer L, Waddell TK, Keshavjee S, Cypel M. Extracorporeal life support as a bridge to lung transplantation-experience of a high-volume transplant center. J Thorac Cardiovasc Surg 2017; 155:1316-1328.e1. [PMID: 29248282 DOI: 10.1016/j.jtcvs.2017.09.161] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 09/10/2017] [Accepted: 09/30/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Extracorporeal life support (ECLS) is increasingly used to bridge deteriorating patients awaiting lung transplantation (LTx), however, few systematic descriptions of this practice exist. We therefore aimed to review our institutional experience over the past 10 years. METHODS In this case series, we included all adults who received ECLS with the intent to bridge to LTx. Data were retrieved from patient charts and our institutional ECLS and transplant databases. RESULTS Between January 2006 and September 2016, 1111 LTx were performed in our institution. ECLS was used in 71 adults with the intention to bridge to LTx; of these, 11 (16%) were bridged to retransplantation. The median duration of ECLS before LTx was 10 days (range, 0-95). We used a single dual-lumen venous cannula in 23 patients (32%). Nine of 13 patients (69%) with pulmonary hypertension were bridged by central pulmonary artery to left atrium Novalung. Twenty-five patients (35%) were extubated while on ECLS and 26 patients (37%) were mobilized. Sixty-three patients (89%) survived to LTx. Survival by intention to treat was 66% (1 year), 58% (3 years) and 48% (5 years). Survival was significantly shorter in patients undergoing ECLS bridge to retransplantation compared with first LTx (median survival, 15 months (95% CI, 0-31) versus 60 months (95% CI, 37-83); P = .041). CONCLUSIONS In our center experience, ECLS bridge to first lung transplant leads to good short-term and long-term outcomes in carefully selected patients. In contrast, our data suggest that ECLS as a bridge to retransplantation should be used with caution.
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Affiliation(s)
- Konrad Hoetzenecker
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Laura Donahoe
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sassan Azad
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Eddy Fan
- Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Pierre
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne Singer
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Single-Site Cannulation Venovenous Extracorporeal CO2 Removal as Bridge to Lung Volume Reduction Surgery in End-Stage Lung Emphysema. ASAIO J 2017; 62:743-746. [PMID: 27465095 DOI: 10.1097/mat.0000000000000421] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we first describe the application of low-flow venovenous extracorporeal CO2 removal (LFVV-ECCO2R) as bridge to LVRS in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute failure of the breathing pump. Between March and October 2015, n = 4 patients received single-site LFVV-ECCO2R as bridge to LVRS. Indication for extracorporeal lung support was severe hypercapnia with respiratory acidosis and acute breathing pump failure. Two patients required continuous mechanical ventilation over a temporary tracheostomy and were bed ridden. The other two patients were nearly immobile because of severe dyspnea at rest. Length of preoperative ECCO2R was 14 (1-42) days. All patients underwent unilateral LVRS. Anatomical resection of the right (n = 3) or left (n = 1) upper lobe was performed. Postoperatively, both patients with previous mechanical ventilatory support were successfully weaned. ECCO2R in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute breathing pump failure is a safe and effective bridging tool to LVRS. In such patients, radical surgery leads to a significant improvement of the performance status and furthermore facilitates respiratory weaning from mechanical ventilation.
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Current State and Future Perspectives of Energy Sources for Totally Implantable Cardiac Devices. ASAIO J 2017; 62:639-645. [PMID: 27442857 DOI: 10.1097/mat.0000000000000412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
There is a large population of patients with end-stage congestive heart failure who cannot be treated by means of conventional cardiac surgery, cardiac transplantation, or chronic catecholamine infusions. Implantable cardiac devices, many designated as destination therapy, have revolutionized patient care and outcomes, although infection and complications related to external power sources or routine battery exchange remain a substantial risk. Complications from repeat battery replacement, power failure, and infections ultimately endanger the original objectives of implantable biomedical device therapy - eliminating the intended patient autonomy, affecting patient quality of life and survival. We sought to review the limitations of current cardiac biomedical device energy sources and discuss the current state and trends of future potential energy sources in pursuit of a lifelong fully implantable biomedical device.
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Parekh M, Abrams D, Brodie D. Extracorporeal techniques in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:296. [PMID: 28828371 DOI: 10.21037/atm.2017.06.58] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) was first introduced for patients with acute respiratory distress syndrome (ARDS) in the 1970s. However, enthusiasm was tempered due to the high mortality seen at that time. The use of ECMO has grown considerably in recent years due to technological advances and the evidence suggesting potential benefit. While the efficacy of ECMO has yet to be rigorously demonstrated with high-quality evidence, it has the potential not only to have a substantial impact on outcomes, including mortality, but also to change the paradigm of ARDS management.
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Affiliation(s)
- Madhavi Parekh
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
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Rajagopal K, Hoeper MM. State of the Art: Bridging to lung transplantation using artificial organ support technologies. J Heart Lung Transplant 2016; 35:1385-1398. [PMID: 27916175 DOI: 10.1016/j.healun.2016.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/05/2016] [Accepted: 10/12/2016] [Indexed: 11/29/2022] Open
Abstract
Lung transplantation increasingly is being performed in recipients of higher risk and acuity. A subset of these patients has severely abnormal gas exchange and/or right ventricular dysfunction, such that artificial organ support strategies are required to bridge patients to lung transplantation. We review the rationales and currently used and potential strategies for bridging to lung transplantation and characterize bridging outcomes. Based on physiologic reasoning and a study of the existing literature, we provide a working strategy for bridging to lung transplantation.
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Affiliation(s)
- Keshava Rajagopal
- Center for Advanced Heart Failure and Department of Cardiothoracic/Vascular Surgery, University of Texas-Houston and Memorial Hermann-Texas Medical Center, Houston, Texas.
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, and German Center for Lung Research (DZL), Hannover, Germany
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37
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Chaparro C, Keshavjee S. Lung transplantation for cystic fibrosis: an update. Expert Rev Respir Med 2016; 10:1269-1280. [DOI: 10.1080/17476348.2016.1261016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Staudinger T. [Extracorporeal lung support-news and future developments]. Med Klin Intensivmed Notfmed 2016; 113:401-408. [PMID: 27379775 DOI: 10.1007/s00063-016-0182-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/02/2016] [Accepted: 03/15/2016] [Indexed: 10/21/2022]
Abstract
Technical developments as well as the experiences during the 2009 influenza pandemia have led to an increased and safer use of extracorporeal gas exchange. Indications are expanding as new systems with the main goal of CO2 elimination have entered the market, thus, broadening the range of systems in addition to classic "high flow" extracorporeal membrane oxygenation (ECMO), although evidence for many suggested indications is sparse or lacking. However, recent research has shed light into the pathophysiology and interaction between the organism and the extracorporeal systems. Upcoming indications like avoiding intubation and mechanical ventilation or reducing invasiveness of ventilation are being evaluated. Novel data and technical advances will keep perspectives of extracorporeal gas exchange dynamic and exciting.
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Affiliation(s)
- T Staudinger
- Universitätsklinik für Innere Medizin I, Intensivstation 13.i2, Allgemeines Krankenhaus der Stadt Wien/Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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40
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Wiegmann B, von Seggern H, Höffler K, Korossis S, Dipresa D, Pflaum M, Schmeckebier S, Seume J, Haverich A. Developing a biohybrid lung – sufficient endothelialization of poly-4-methly-1-pentene gas exchange hollow-fiber membranes. J Mech Behav Biomed Mater 2016; 60:301-311. [DOI: 10.1016/j.jmbbm.2016.01.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/22/2016] [Accepted: 01/27/2016] [Indexed: 11/29/2022]
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Manap HH, Abdul Wahab AK. Extracorporeal carbon dioxide removal (ECCO 2R) in respiratory deficiency and current investigations on its improvement: a review. J Artif Organs 2016; 20:8-17. [PMID: 27193131 DOI: 10.1007/s10047-016-0905-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 05/05/2016] [Indexed: 01/27/2023]
Abstract
The implementation of extracorporeal carbon dioxide removal (ECCO2R) as one of the extracorporeal life support system is getting more attention today. Thus, the objectives of this paper are to study the clinical practice of commercial ECCO2R system, current trend of its development and also the perspective on future improvement that can be done to the existing ECCO2R system. The strength of this article lies in its review scope, which focuses on the commercial ECCO2R therapy in the market based on membrane lung and current investigation to improve the efficiency of the ECCO2R system, in terms of surface modification by carbonic anhydrase (CA) immobilization technique and respiratory electrodialysis (R-ED). Our methodology approach involves the identification of relevant published literature from PubMed and Web of Sciences search engine using the terms Extracorporeal Carbon Dioxide Removal (ECCO2R), Extracorporeal life support, by combining terms between ECCO2R and CA and also ECCO2R with R-ED. This identification only limits articles in English language. Overall, several commercial ECCO2R systems are known and proven safe to be used in patients in terms of efficiency, safety and risk of complication. In addition, CA-modified hollow fiber for membrane lung and R-ED are proven to have good potential to be applied in conventional ECCO2R design. The detailed technique and current progress on CA immobilization and R-ED development were also reviewed in this article.
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Affiliation(s)
- Hany Hazfiza Manap
- Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Ahmad Khairi Abdul Wahab
- Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, 50603, Kuala Lumpur, Malaysia. .,Centre for Separation Science and Technology (CSST), Department of Chemical Engineering, Faculty of Engineering, University of Malaya, 50603, Kuala Lumpur, Malaysia.
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Makdisi G, Makdisi PB, Wang IW. New horizons of non-emergent use of extracorporeal membranous oxygenator support. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:76. [PMID: 27004223 DOI: 10.3978/j.issn.2305-5839.2016.02.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The expansion of the extra corporeal membrane oxygenation (ECMO) use and its indication is strikingly increased in the past few years. ECMO use expanded to lung transplantation, difficult general thoracic resections, transcatheter aortic valve replacement (TAVR) and LVAD implantation. Here we will discuss the indications and the outcomes of non-emergent use of ECMO.
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Affiliation(s)
- George Makdisi
- 1 Gulf Coast Cardiothoracic Surgery Institute, Tampa General Hospital, Tampa, FL, USA ; 2 Mayo Clinic College of Medicine, Rochester, MN, USA ; 3 Indiana University School of Medicine, Division of Cardiothoracic Surgery, Indiana University Health, Methodist Hospital, Indianapolis, IN, USA
| | - Peter B Makdisi
- 1 Gulf Coast Cardiothoracic Surgery Institute, Tampa General Hospital, Tampa, FL, USA ; 2 Mayo Clinic College of Medicine, Rochester, MN, USA ; 3 Indiana University School of Medicine, Division of Cardiothoracic Surgery, Indiana University Health, Methodist Hospital, Indianapolis, IN, USA
| | - I-Wen Wang
- 1 Gulf Coast Cardiothoracic Surgery Institute, Tampa General Hospital, Tampa, FL, USA ; 2 Mayo Clinic College of Medicine, Rochester, MN, USA ; 3 Indiana University School of Medicine, Division of Cardiothoracic Surgery, Indiana University Health, Methodist Hospital, Indianapolis, IN, USA
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Rosskopfova P, Perentes JY, Ris HB, Gronchi F, Krueger T, Gonzalez M. Extracorporeal support for pulmonary resection: current indications and results. World J Surg Oncol 2016; 14:25. [PMID: 26837543 PMCID: PMC4736123 DOI: 10.1186/s12957-016-0781-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/26/2016] [Indexed: 12/21/2022] Open
Abstract
Extracorporeal assistances are exponentially used for patients, with acute severe but reversible heart or lung failure, to provide more prolonged support to bridge patients to heart and/or lung transplantation. However, experience of use of extracorporeal assistance for pulmonary resection is limited outside lung transplantation. Airways management with standard mechanical ventilation system may be challenging particularly in case of anatomical reasons (single lung), presence of respiratory failure (ARDS), or complex tracheo-bronchial resection and reconstruction. Based on the growing experience during lung transplantation, more and more surgeons are now using such devices to achieve good oxygenation and hemodynamic support during such challenging cases. We review the different extracorporeal device and attempt to clarify the current practice and indications of extracorporeal support during pulmonary resection.
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Affiliation(s)
- Petra Rosskopfova
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jean Yannis Perentes
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Hans-Beat Ris
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Fabrizio Gronchi
- Division of Thoracic Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thorsten Krueger
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Michel Gonzalez
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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Mayes J, Niranjan G, Dark J, Clark S. Bridging to lung transplantation for severe pulmonary hypertension using dual central Novalung lung assist devices. Interact Cardiovasc Thorac Surg 2016; 22:677-8. [PMID: 26819271 DOI: 10.1093/icvts/ivv393] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/09/2015] [Indexed: 11/13/2022] Open
Abstract
This case describes the technique of using dual Novalungs (a pumpless extracorporeal system) to bridge a patient with idiopathic pulmonary hypertension to bilateral lung transplantation. A 41-year old lady with idiopathic pulmonary hypertension (with a possible veno-occlusive element) presented with symptoms of end-stage heart and lung failure. This was refractory to medical management with iloprost, sildenafil and bosentan. The patient was placed on the urgent waiting list for lung transplantation and central pulmonary artery to left atrial Novalung insertion was performed. Local anaesthetic was given before performing peripheral cardiopulmonary bypass due to the high risk of cardiac arrest. Two days later, donor organs became available and the patient was taken for double-lung transplantation. The pulmonary artery cannula was removed leaving a large defect. This was then closed using a bovine pericardial patch. Due to the damaged right superior pulmonary vein from Novalung cannulation, cardioplegia was given to facilitate an open atrial anastomosis. After 13 days in the intensive therapy unit, she was transferred to the ward. There were no further complications and she has been discharged home.
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Affiliation(s)
| | | | - John Dark
- Newcastle University, Newcastle upon Tyne, UK Freeman Hospital, Newcastle upon Tyne, UK
| | - Stephen Clark
- Freeman Hospital, Newcastle upon Tyne, UK Northumbria University, Newcastle upon Tyne, UK
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45
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Bednarsch J, Menk M, Malinowski M, Weber-Carstens S, Pratschke J, Stockmann M. (13) C Breath Tests Are Feasible in Patients With Extracorporeal Membrane Oxygenation Devices. Artif Organs 2015; 40:692-8. [PMID: 26527580 DOI: 10.1111/aor.12634] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Temporary extracorporeal membrane oxygenation (ECMO) has been established as an essential part of therapy in patients with pulmonary or cardiac failure. As physiological gaseous exchange is artificially altered in this patient group, it is debatable whether a (13) C-breath test can be carried out. In this proof of technical feasibility report, we assess the viability of the (13) C-breath test LiMAx (maximum liver function capacity) in patients on ECMO therapy. All breath probes for the test device were obtained directly via the membrane oxygenator. Data of four patients receiving liver function assessment with the (13) C-breath test LiMAx while having ECMO therapy were analyzed. All results were compared with validated scenarios of the testing procedures. The LiMAx test could successfully be carried out in every case without changing ECMO settings. Clinical course of the patients ranging from multiorgan failure to no sign of liver insufficiency was in accordance with the results of the LiMAx liver function test. The (13) C-breath test is technically feasible in the context of ECMO. Further evaluation of (13) C-breath test in general would be worthwhile. The LiMAx test as a (13) C-breath test accessing liver function might be of particular predictive interest if patients with ECMO therapy develop multiorgan failure.
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Affiliation(s)
- Jan Bednarsch
- Department of General, Visceral and Transplantation Surgery, Charité University Medicine Berlin, Berlin, Germany.,Department of General, Visceral and Transplantation Surgery, Rhine Westphalia Institute of Technology, University Clinic Aachen, Aachen, Germany
| | - Mario Menk
- Department of Anaesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany
| | - Maciej Malinowski
- Department of General, Visceral and Transplantation Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplantation Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Martin Stockmann
- Department of General, Visceral and Transplantation Surgery, Charité University Medicine Berlin, Berlin, Germany
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46
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Banayan JM, Roberts JD, Chaney MA, Odonkor PN, Hosseinian L, Torregrossa G. CASE 7-2016 Choice of Percutaneous Mechanical Assistance During Cardiopulmonary Instability: Heart, Lungs, or Both? J Cardiothorac Vasc Anesth 2015; 30:1104-17. [PMID: 26755437 DOI: 10.1053/j.jvca.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Jennifer M Banayan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| | - J Devin Roberts
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Patrick N Odonkor
- Department of Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Leila Hosseinian
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
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47
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Outcome of Extracorporeal Membrane Oxygenation as a Bridge To Lung Transplantation. Transplantation 2015; 99:1667-71. [DOI: 10.1097/tp.0000000000000653] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Lehr CJ, Zaas DW, Cheifetz IM, Turner DA. Ambulatory extracorporeal membrane oxygenation as a bridge to lung transplantation: walking while waiting. Chest 2015; 147:1213-1218. [PMID: 25940249 DOI: 10.1378/chest.14-2188] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The proportion of critically ill patients awaiting lung transplantation has increased since the implementation of the Lung Allocation Score (LAS) in 2005. Critically ill patients comprise a sizable proportion of wait-list mortality and are known to experience increased posttransplant complications. These critically ill patients have been successfully bridged to lung transplantation with extracorporeal membrane oxygenation (ECMO), but historically these patients have required excessive sedation, been immobile, and have had difficult functional recovery in the posttransplant period and high mortality. One solution to the deconditioning often seen in critically ill patients is the implementation of rehabilitation and ambulation while awaiting transplantation on ECMO. Ambulatory ECMO programs of this nature have been developed in an attempt to provide rehabilitation, physical therapy, and minimization of sedation prior to lung transplantation to improve both surgical and posttransplant outcomes. Favorable outcomes have been reported using this novel approach, but how and where this strategy should be implemented remain unclear. In this commentary, we review the currently available literature for ambulation and rehabilitation during ECMO support as a bridge to lung transplantation, discuss future directions for this technology, and address the important issues of resource allocation and regionalization of care as they relate to ambulatory ECMO.
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Affiliation(s)
- Carli J Lehr
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Duke University Hospital and Health System
| | - David W Zaas
- Duke Raleigh Hospital, Department of Pediatrics, Duke Children's Hospital, Durham, NC
| | - Ira M Cheifetz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, NC
| | - David A Turner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, NC.
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Corris P, Degano B. Severe pulmonary arterial hypertension: treatment options and the bridge to transplantation. Eur Respir Rev 2015; 23:488-97. [PMID: 25445947 DOI: 10.1183/09059180.00007214] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease leading to right heart failure and death. Prognosis remains poor, particularly for patients with severe disease, i.e. World Health Organization functional class IV. There have been significant improvements in treatment options. Several agents are available that target the three main established PAH disease pathways, and can be combined sequentially or upfront. Strong scientific evidence supports the use of intravenous epoprostenol in severe PAH; however, despite recommendations, many patients do not receive parenteral prostanoids and there is a lack of evidence from randomised clinical trials supporting the value of other PAH medications alone in severe PAH. Lung transplantation is an important option in patients with severe PAH who have not responded sufficiently to therapy, or who have worsened despite maximal treatment. Bridging techniques are available for patients who worsen while awaiting transplantation. The type of bridging technique used depends on various factors including patient illness severity, physician experience and the anticipated waiting time for transplantation. With the aim to facilitate the treatment decision-making process, herein we review the medical treatment options available for patients with severe PAH, and the bridging techniques that may be used to sustain patients awaiting transplantation.
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Affiliation(s)
- Paul Corris
- Institute of Cellular Medicine, Newcastle University and the Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. Service de Physiologie-Exploration Fonctionnelles, CHRU, et EA 3920, Université de Franche-Comté, Besançon, France
| | - Bruno Degano
- Institute of Cellular Medicine, Newcastle University and the Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. Service de Physiologie-Exploration Fonctionnelles, CHRU, et EA 3920, Université de Franche-Comté, Besançon, France
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50
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Bennett SC, Beal EW, Dumond CA, Preston T, Ralston J, Pope-Harman A, Black S, Hayes Jr D, Whitson BA. Mechanical circulatory support in lung transplantation: Cardiopulmonary bypass, extracorporeal life support, and ex-vivo lung perfusion. World J Respirol 2015; 5:78-92. [DOI: 10.5320/wjr.v5.i2.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 03/15/2015] [Accepted: 04/20/2015] [Indexed: 02/06/2023] Open
Abstract
Lung transplant is the standard of care for patients with end-stage lung disease refractory to medical management. There is currently a critical organ shortage for lung transplantation with only 17% of offered organs being transplanted. Of those patients receiving a lung transplant, up to 25% will develop primary graft dysfunction, which is associated with an 8-fold increase in 30-d mortality. There are numerous mechanical lung assistance modalities that may be employed to help combat these challenges. We will discuss the use of mechanical lung assistance during lung transplantation, as a bridge to transplant, as a treatment for primary graft dysfunction, and finally as a means to remodel and evaluate organs deemed unsuitable for transplant, thus increasing the donor pool, improving survival to transplant, and improving overall patient survival.
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