ECMO and MCS in Naples

Dr. Cristiano Amarelli Perfusionist: Emanuele Petrazzuolo

Department of Cardiothoracic Surgery and TransplantsSecond University of Naples

Monaldi HospitalNapoli

Heart Transplantation 1988-2010558 transplants on 553 patients (12 pediatrics)

108

68 9

12

20

32

38

2827

22

34

28

37

32

3639

3230 28

24

18

0

5

10

15

20

25

30

35

40

'88

'89

'90

'91

'92

'93

'94

'95

'96

'97

'98

'99

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Centro Nazionale TrapiantiCentro Nazionale Trapianti

Trapianti di CUORE – Anni 1992/2010*Trapianti di CUORE – Anni 1992/2010*

Inclusi i trapianti Inclusi i trapianti combinati combinati

Inclusi i trapianti Inclusi i trapianti combinati combinati

FONTE DATI: Dati Reports CIRFONTE DATI: Dati Reports CIR

*Dati definitivi al Agosto 2010

MCS 2007-2010MCS 2007-201022 MCS on 15 patients22 MCS on 15 patients

MCS 2007-2010MCS 2007-201022 MCS on 15 patients22 MCS on 15 patients

8

7

Oxygenator

4+3

Experience in Naples with ventricular assistancesExperience in Naples with ventricular assistances199519952007 9 Novacor 2007 9 Novacor

Experience in Naples with ventricular assistancesExperience in Naples with ventricular assistances199519952007 9 Novacor 2007 9 Novacor

20072007 1 ABIOMED died for infection before heart transplantation 1 ABIOMED died for infection before heart transplantation Intermacs 3 Intermacs 3 1 ABIOMED 1 ABIOMED crash and burn crash and burn

20082008 1 De Bakey 1 De Bakey crash and burncrash and burn

2009 2009 4 4 LEVITRONIXLEVITRONIX

V. M. RVAD (Levitronix) + LVAS (Heartmate)V. M. RVAD (Levitronix) + LVAS (Heartmate) Intermacs 2Intermacs 2 OKOK S. G. RVAD (Levitronix post Redo for Prosthetic Endocarditis) S. G. RVAD (Levitronix post Redo for Prosthetic Endocarditis) crash and burn crash and burn OKOK S. A. ECMO per IR after Emergent Mitral Rupture S. A. ECMO per IR after Emergent Mitral Rupture crash and burncrash and burn S. D. LVAS (Heartmate) S. D. LVAS (Heartmate) RVAD (Levitronix) and upgrade to V-V ECMO (Levitronix) RVAD (Levitronix) and upgrade to V-V ECMO (Levitronix)

2010 2010 5 5 LEVITRONIX LEVITRONIX + 3 ARDS Percutaneous ECMO Giug + 3 ARDS Percutaneous ECMO GiugFemFem

Z. S. RVAD(Levitronix)+LVAS (Heartmate)Z. S. RVAD(Levitronix)+LVAS (Heartmate)RVAD RemovalRVAD RemovalRVFRVF Intermacs 2Intermacs 2 G. M. Berlin Heart G. M. Berlin Heart Intermacs 2Intermacs 2 OKOK G. M. Berlin Heart Infection (7months)G. M. Berlin Heart Infection (7months) TransplantTransplant ECMO ECMO crash and burncrash and burn OKOK K. K. ECMO post-cardiotomy failure K. K. ECMO post-cardiotomy failure TransplantTransplant crash and burncrash and burn B. A. ECMO post cardiotomy failure B. A. ECMO post cardiotomy failure Transplant Transplant crash and burncrash and burn OKOK D. F. RVAD (in operata di DIV) D. F. RVAD (in operata di DIV) crash and burncrash and burn OKOK

20072007 1 ABIOMED died for infection before heart transplantation 1 ABIOMED died for infection before heart transplantation Intermacs 3 Intermacs 3 1 ABIOMED 1 ABIOMED crash and burn crash and burn

20082008 1 De Bakey 1 De Bakey crash and burncrash and burn

2009 2009 4 4 LEVITRONIXLEVITRONIX

V. M. RVAD (Levitronix) + LVAS (Heartmate)V. M. RVAD (Levitronix) + LVAS (Heartmate) Intermacs 2Intermacs 2 OKOK S. G. RVAD (Levitronix post Redo for Prosthetic Endocarditis) S. G. RVAD (Levitronix post Redo for Prosthetic Endocarditis) crash and burn crash and burn OKOK S. A. ECMO per IR after Emergent Mitral Rupture S. A. ECMO per IR after Emergent Mitral Rupture crash and burncrash and burn S. D. LVAS (Heartmate) S. D. LVAS (Heartmate) RVAD (Levitronix) and upgrade to V-V ECMO (Levitronix) RVAD (Levitronix) and upgrade to V-V ECMO (Levitronix)

2010 2010 5 5 LEVITRONIX LEVITRONIX + 3 ARDS Percutaneous ECMO Giug + 3 ARDS Percutaneous ECMO GiugFemFem

Z. S. RVAD(Levitronix)+LVAS (Heartmate)Z. S. RVAD(Levitronix)+LVAS (Heartmate)RVAD RemovalRVAD RemovalRVFRVF Intermacs 2Intermacs 2 G. M. Berlin Heart G. M. Berlin Heart Intermacs 2Intermacs 2 OKOK G. M. Berlin Heart Infection (7months)G. M. Berlin Heart Infection (7months) TransplantTransplant ECMO ECMO crash and burncrash and burn OKOK K. K. ECMO post-cardiotomy failure K. K. ECMO post-cardiotomy failure TransplantTransplant crash and burncrash and burn B. A. ECMO post cardiotomy failure B. A. ECMO post cardiotomy failure Transplant Transplant crash and burncrash and burn OKOK D. F. RVAD (in operata di DIV) D. F. RVAD (in operata di DIV) crash and burncrash and burn OKOK

Experience in NaplesExperience in NaplesComplicationsComplicationsExperience in NaplesExperience in NaplesComplicationsComplications

2007 2007 2 surgical revisions for bleeding on the same 2 surgical revisions for bleeding on the same patient patient

2009 2009

Cerebral Hemorrhage after 8 monthsCerebral Hemorrhage after 8 months1 surgical revision for Pulmonary Cannula migration1 surgical revision for Pulmonary Cannula migrationCerebral Hemorrhage after 1 monthCerebral Hemorrhage after 1 month

2010 2010

Right Ventricular failure after RVAD removalRight Ventricular failure after RVAD removal1 surgical revision for atrial tamponade1 surgical revision for atrial tamponade1 surgical revision for bleeding1 surgical revision for bleeding

2007 2007 2 surgical revisions for bleeding on the same 2 surgical revisions for bleeding on the same patient patient

2009 2009

Cerebral Hemorrhage after 8 monthsCerebral Hemorrhage after 8 months1 surgical revision for Pulmonary Cannula migration1 surgical revision for Pulmonary Cannula migrationCerebral Hemorrhage after 1 monthCerebral Hemorrhage after 1 month

2010 2010

Right Ventricular failure after RVAD removalRight Ventricular failure after RVAD removal1 surgical revision for atrial tamponade1 surgical revision for atrial tamponade1 surgical revision for bleeding1 surgical revision for bleeding

Surgical Tecnique and methods Surgical Tecnique and methods Surgical Tecnique and methods Surgical Tecnique and methods

Double Tobacco Pursestring on teflon feltDouble Tobacco Pursestring on teflon felt

Tourniquets Secured Tying Suture on a small Teflon FeltTourniquets Secured Tying Suture on a small Teflon Felt

Application of spray VIVOSTAT Fibrin SealantApplication of spray VIVOSTAT Fibrin Sealant

Double Tobacco Pursestring on teflon feltDouble Tobacco Pursestring on teflon felt

Tourniquets Secured Tying Suture on a small Teflon FeltTourniquets Secured Tying Suture on a small Teflon Felt

Application of spray VIVOSTAT Fibrin SealantApplication of spray VIVOSTAT Fibrin Sealant

V.M. 24/06/2009V.M. 24/06/2009V.M. 24/06/2009V.M. 24/06/2009

Patient Characteristic

Male, 62 y

60 Kg x 160 cm

Post-ischemic Cardiomiopathy

IACD BiV

Chronic Renal Failure

Chronic Peripheral Arteriopathy

Postoperative Course

On 3° p.o. Estubated

On 20° p.o. RVAD Removed

On 64° p.o. Discharged

Type of MCS

Levitronix: Right Atrium PA

Heartmate II

RVAD Course

No Bleeding

Optimal RV unloading (PVC 3)

Lac on ICU 2,2 mmol/L

RBC Units PFC Units

G. M. 07/03/2010 G. M. 07/03/2010 G. M. 07/03/2010 G. M. 07/03/2010

Patient Characteristic

Female, 10 y

24 Kg x 115 cm

Post-myocarditis

On November 2009 Excor BVAD

Transplanted on 07/03/2010

Donor: 15 Kg 5 Years old

Postoperative Course

On 5° p.o. Estubated

On 7° p.o. ECMO Removed

On 72°p.o. Discharged

Now on I NYHA

Type of MCS

After CPB Levitronix:

Right Atrium Aorta

ECMO Course

Surgical Revision for Bleeding

RBC 15 Units PFC 18 Units

B.A. 25/05/2010B.A. 25/05/2010B.A. 25/05/2010B.A. 25/05/2010

Patient CharacteristicFemale, 66 y

72 Kg x 160 cm

Elective Mitral Replacement

HCV + RNA-

Postoperative CourseOn 2° p.o. Hour Cardiogenic shock

CPR and IABP

During CPR transferred in OR

Type of MCSLevitronix:Right Atrium Aorta

ECMO CourseLac in ICU: 6,3 mmol/L

PO2>150 mmHg PCO2 OK

I Day Drainage 425 cc

II day: Revision for Atrial tamponade

IV Day: Heart Transplantation

V Day: IABP Removed

RBC 10 Units, PFC 12 Units

Still Hospidalized for Pulmonary Infection

Pulmonary Cannula Migration in LPAPulmonary Cannula Migration in LPAPulmonary Cannula Migration in LPAPulmonary Cannula Migration in LPA

Pulmonary Cannula Migration in LPAPulmonary Cannula Migration in LPAPulmonary Cannula Migration in LPAPulmonary Cannula Migration in LPA

Experience in Naples with Respiratory ECMOExperience in Naples with Respiratory ECMOExperience in Naples with Respiratory ECMOExperience in Naples with Respiratory ECMO

2010 2010 3 ARDS 3 ARDS Percutaneous ECMO GiugPercutaneous ECMO GiugFem Fem MEDOSHILITE LAEVITRONICS MEDOSHILITE LAEVITRONICS

P. R. 22 y H1N1 Infection Duration 28 ggP. R. 22 y H1N1 Infection Duration 28 gg C. P. 28 y H1N1 Infection Duration 12 ggC. P. 28 y H1N1 Infection Duration 12 gg P. G. 34 y H1N1 Infection Duration 30 ggP. G. 34 y H1N1 Infection Duration 30 gg

2010 2010 3 ARDS 3 ARDS Percutaneous ECMO GiugPercutaneous ECMO GiugFem Fem MEDOSHILITE LAEVITRONICS MEDOSHILITE LAEVITRONICS

P. R. 22 y H1N1 Infection Duration 28 ggP. R. 22 y H1N1 Infection Duration 28 gg C. P. 28 y H1N1 Infection Duration 12 ggC. P. 28 y H1N1 Infection Duration 12 gg P. G. 34 y H1N1 Infection Duration 30 ggP. G. 34 y H1N1 Infection Duration 30 gg

Paziente ECMO: P.R. aa 22, IVDUPaziente ECMO: P.R. aa 22, IVDUPaziente ECMO: P.R. aa 22, IVDUPaziente ECMO: P.R. aa 22, IVDU

Ventilation Duration Pre-ECMOVentilation Duration Pre-ECMO 3 d3 d

ICU StayICU Stay 30d (28d in ECMO)30d (28d in ECMO)

Blood Flow 1° h (Liters/min) Blood Flow 1° h (Liters/min) 5, 07 5, 07

Blood Flow 1° d (Liters/min) Blood Flow 1° d (Liters/min) 3.73 3.73

Gas Flow 1°d (Liters/min) Gas Flow 1°d (Liters/min) 4.654.65

PTT ratio PTT ratio 41.941.9

Oxygenator Model Oxygenator Model MEDOSHILITE LAEVITRONICS MEDOSHILITE LAEVITRONICS

ECMO - CannulationECMO - Cannulation GiugularGiugularFemoralFemoral

VAM modalityVAM modality BIPAPBIPAP

ConclusionsConclusionsConclusionsConclusions

ECMO can be a lifesaving strategy in patients with ECMO can be a lifesaving strategy in patients with end-stage circulatory and respiratory failure.end-stage circulatory and respiratory failure.

Results are strictly related to the Results are strictly related to the reversibilityreversibility of the of the underlying disease and the underlying disease and the timingtiming of the indication. of the indication.

Anticoagulation management is still a challenge in Anticoagulation management is still a challenge in the setting of Circulatory Support with central the setting of Circulatory Support with central ECMO.ECMO.

ECMO can be a lifesaving strategy in patients with ECMO can be a lifesaving strategy in patients with end-stage circulatory and respiratory failure.end-stage circulatory and respiratory failure.

Results are strictly related to the Results are strictly related to the reversibilityreversibility of the of the underlying disease and the underlying disease and the timingtiming of the indication. of the indication.

Anticoagulation management is still a challenge in Anticoagulation management is still a challenge in the setting of Circulatory Support with central the setting of Circulatory Support with central ECMO.ECMO.