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Division of Cardiopulmonary Transplantation, Department of Cardiothoracic Surgery, Duke University Medical Center, 3582 Duke Hospital South, Box 3864, Durham, NC 27710
(Email: reddylcs{at}gmail.com).
The use of arteriovenous extracorporeal membrane oxygenation (ECMO), as an extended measure of cardiopulmonary resuscitation, also known as E-CPR, has a definite role; however, it is small and ill defined. In patients where cardiac recovery is anticipated, it is an unpredictable and unknown entity. Often, this is a bridging option to either a transplant or a more definitive mechanical assist device, which in itself may be a further bridge to transplantation or destination therapy. The ease and speed with which this can be instituted with percutaneous cannulation (borrowed from port access techniques), offers its appealing advantage.
Patients treated with E–CRP progress through three distinct phases during their treatment. The first phase involves technical and circulatory issues. Placement of an appropriate sized venous cannula and establishing adequate tissue perfusion should achieve metabolic resuscitation within a few hours. The second phase involves inflammation, characterized by a complete whiteout of the lung fields. Avoiding high fractional inspiratory oxygen (FiO2) and high positive end-expiratory pressure on nonfunctional lungs will facilitate recovery. Renal dysfunction in those with marginal renal status will require filtration through the circuit or dialysis as a supportive measure. The third phase involves infection and end-organ failure. Proactive regular surveillance cultures from the circuit and the patient are required, along with broad spectrum antibiotics and antifungals as appropriate. Heparin resistance and sensitivity are not unusual and need vigilance during ECMO management. Regular neurologic assessment with clinical and radiologic means is important in all of these patients.
In this study, Dr Thiagarajan and colleagues [1], present a comprehensive audit of the outcomes in 295 patients. The findings are supportive of the experience in the centers that undertake this intervention. The use of ECMO has increased in recent years, although not with improved outcomes. This reflects on the willingness of the centers to be aggressive toward managing their patients. Further studies will help in patient selection in the future. Neurologic injury, sepsis, and multiorgan failure are the nemesis of this treatment. Even though this study could not evaluate the impact of large volume centers, it is reasonable to expect that large volume centers have more to offer toward better outcomes.
With a growing need and increasing expertise of most centers in providing mechanical circulatory assist devices, I see a more definitive role for E-CRP evolving in the future.
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