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Franco Valenza
Department of Pathophysiology and Transplantation
Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
New perspectives in ECMO 2012
ECMO and lung transplant program
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No conflict of interest
New perspectives in ECMO 2012
ECMO and lung transplant program
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New perspectives in ECMO 2012
ECMO and lung transplant program
Conventional
Un-conventional
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ECMO - Bridge ECMO - PGDECMO - Support
Conventional
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ECMO - Bridge ECMO - PGDECMO - Support
before during after
Lung Transplantation
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ECMO - SupportECMO - Bridge ECMO - PGD
Hemodynamics
Hypoxia - Hypercapnia
Anticoagulation
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Wen-Je, Artifical Organs (2001); 25(8):607
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Bittner, Eur J Cardio Thor Surg (2007); 31: 462
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Burdett, Inter CardioVasc Thor Surg (2012);15:432
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ECMO Pre Intra Post RBC FFP PLT Redo Bleeding
1 Bil Yes VV (6) VV VV (1) 7 4
2 Bil Yes VV (6) VA VV (2) 21 28 2
3 Bil 3 3
4 2 0
5 Bil Yes VA 3 2 Yes
6 Bil Yes VV (4) VV VV (1) 8 8 1
7 Bil Yes VV (3) VA VV (5) 19 28 2 Yes Yes
8 Bil 2
9 Bil Yes VA 32 24 5 Yes
10 Yes VV
11 Yes VA 5
12 Yes VV (9) VA VV (1) 28 30 3 Yes
13 2 1
14 1
15
16 Bil 3 6
17 Bil 5 4
18 4
19
20
Ca’ Granda, from 3/2011 to present
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# RBC FFP
ECMOno ECMO
911
8 (1-24)2 (0-3) * 0.038
14 ± 131 ± 2 * 0.004
VAVV
63
17 ± 135 ± 4 0.171
19 ± 134 ± 4 0.083
VA + bridgeVA
33
22 ± 512 ± 18 0.356
29 ± 110 ± 12 0.057
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# RBC FFP
ECMOno ECMO
911
8 (1-24)2 (0-3) * 0.038
14 ± 131 ± 2 * 0.004
VAVV
63
17 ± 135 ± 4 0.171
19 ± 134 ± 4 0.083
VA + bridgeVA
33
22 ± 512 ± 18 0.356
29 ± 110 ± 12 0.057
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ECMO - Bridge ECMO - PGDECMO - Support
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Year
1990 1995 2000 2005 2010
n. o
f re
fere
nce
s
0
5
10
15
20
ECMO Bridge Lung TransplantationPub Med search
Lang, Transplantation (2012);93:729Bittner, Ann Thor Surg (2012);94:942
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Year
1990 1995 2000 2005 2010
n. o
f re
fere
nce
s
0
5
10
15
20
ECMO Bridge Lung TransplantationPub Med search
Ambulatory ECMO bridge
Early vs. Late
Awake vs.Intubated
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ECMO - Bridge ECMO - Support ECMO - PGD
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Postoperative “treatment” tool
Oto, Ann Thor Surg (2004);78:1230
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Low perfusion pressure
Bhabra, Ann Thor Surg 1996;61:1631Bhabra, Ann Thor Surg 1998;65:187
Pierre, J Thorac Cardiovasc Surg 1998;116:932Clark, J Thorac Cardiovasc Surg 1998;115:1335
Halldorsson, J Thorac Cardiovasc Surg 1998;115:415
De Perrot, J Thorac Cardiovasc Surg 2002;124:1137 Crimi, Am J respir Crit Care Med 2005;174:178
Chiang, Resuscitation 2008;79:147
Protective ventilation
Valenza, Organ Tissue & Cells (2012)
Intraoperative “prevention” tool
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McILwain, Lab Invest (2010);90:128
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0
10
20
30
40
50
60
70
MCP-1
0
1
2
3
4
CXCL-10
0
2
4
6
8
10
12
14
16
18
20
IL-8
Control BD Ischemia Graft
Rel
ativ
e ex
pre
ssio
n
*
*
*
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
HMGB-1
*
Valenza, un published
Control BD Ischemia Graft
Control BD Ischemia Graft Control BD Ischemia Graft
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Valenza, un published
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New perspectives in ECMO 2012
ECMO and lung transplant program
Conventional
Un-conventional
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ECMO - Bridge ECMO - PGDECMO - Support
RECIPIENT
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ECMO - Bridge ECMO - PGDECMO - Support
RECIPIENT
reverse - ECMO
LUNG DONOR
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reverse - ECMOEx-Vivo Lung Perfusion (EVLP)
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Cypel, NEJM (2011);364:1431
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*
Valenza, Transpl Proc (2012); 44:1826-9
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ECMO - Bridge ECMO - PGDECMO - Support
RECIPIENT
donor - ECMO
reverse - ECMO
LUNG DONOR
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LUNG DONOR
Lung Harvest
Transplantation
BRAIN DEATH
Maastricht III
CARDIAC DEATH
EVLPMaastricht II
ECMO
Refractory cardiogenic shock
ECMOMaastricht VI
Liver OLTX
Rat Lungs
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…. in conclusion
LUNG DONOR
RECIPIENTBridge
SupportPGD
EVLPDCD
No way I’m gonna stay with-out ECMO!
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…. thanks for your attention!