“bECMO”: If You Build It, We Will Pump Case report using a Berlin Heart with an ECMO Oxygenator Jerri Hilshorst CCP, Aimee Gardner CCP, John Lombardi CCP, Robert Ferguson CCP, Angela Lorts MD, Pirooz Egthesady MD, Peter Manning MD
“bECMO”: If You Build It, We Will PumpCase report using a Berlin Heart with an ECMO
Oxygenator
Jerri Hilshorst CCP, Aimee Gardner CCP, John Lombardi CCP, Robert Ferguson CCP, Angela Lorts MD, Pirooz Egthesady MD, Peter Manning MD
Two Questions:
Third Question
Camboni, et al. Serial Use of an Interventional Lung Assist Device and Ventricular Assist Device, ASAIO J 2010.
Berlin ECMO Oxygenator
“bECMO”
2011 Berlin Experience at Cincinnati Children’s
• 2011: n=7
5 successfully transplanted
1 converted back to ECMO, H Tx, died
1 converted back to ECMO, died
Patient BackgroundMale Infant with Barth Syndrome (BTHS)
• Rare (1 in 300,000 births) genetic disorder characterized by:• Cardiomyopathy (dilated or hypertrophic)• Neutropenia• Muscle hypoplasia & weakness• Growth delay• Mitochondria dysfunction• X-linked
Patient Background
• Presented at 3 days life in cardiogenic shock• Maximum inotropic support• Routine genetic evaluation was normal• End organ dysfunction persisted• Further genetic testing revealed BTHS• Prolonged hospitalization• Improved on medical CHF management.• Discharged to home
Patient BackgroundAt 1 yr of life (7.5 kg, 66cm)
• Dilated Cardiomyopathy, left ventricular non compaction, Barth Syndrome
• Cardiac function declined; EF 12%• Increased CHF symptoms• Re-admitted to CCU & listed for H Tx• V-tach, deteriorating CO on max inotropic
support, elevated Creat • Urgent VAD placement
Patient ManagementCBP & LVAD Placement
• CPB initiated 2 hour pump run• Berlin 10mL LVAD pump• 6 mm LV apex and Ao cannulae• CPB terminated
Patient ManagementLVAD only
• Return normal sinus rhythm• Borderline hemodynamics• Intraoperative TEE: ↓↓↓ RV function• Resulted in poor LVAD filling
Patient Management+ RVAD = Bi-VAD
• Returned to CPB; 1hr 6 min• Placed Berlin 10mL RVAD pump• 6 mm RA and PA cannulae• CPB terminated
L ♥
R ♥
6mm from RA
6mm to PA
6mm from Apex
6mm to Ao
RVAD
10 mL
LVAD
10 mL
Berlin biVAD Circuit
Patient ManagementBiVAD Performance• After initiation biVAD, pt received numerous
blood products & Factor VII• Pulmonary hemorrhage→ Poor Oxygenation• High airway pressures→ ↑PVR• ↓RVAD ejection• ↓LVAD filling
Patient ManagementOxygenator Placement• Surgeon decided to splice in Quadrox
pediatric oxygenator• Obtained a blood primed Quadrox from
ECMO team• He built it and we pumped!
L ♥
R ♥
6mm from RA
6mm to PA
6mm from Apex
6mm to Ao
RVAD
10 mL
LVAD
10 mL
bECMO Circuit
OXY
RVAD
LVAD
QUADROX OXYGENATOR
FLOW PROBE
PRE MEMB PRES
POST MEMB PRES
HEAT EXCHANGER
From RA to RVAD
To Quadrox
R ♥L ♥
To PA
bECMO Settings
• Berlin Flow: 1 LPM (10mLpump x 100bpm)• MODE: Synchronous• RATE: 100 bpm• L & R DRIVE PRESS systole: 180 mmHg• L & R DRIVE PRESS diastole: -50 mmHg• % SYSTOLE: L=40
R=50
Berlin
bECMO Settings
• Actual Flow: 0.7 – 0.8 LPM (Transonic Q probe)• prePres = 50 mmHg (ave)• postPres 25 mm Hg (ave)• Sweep: 1 – 2 LPM (begin – ↑ - oxy off)• FiO2: 100% - 0% (begin – ↓ - oxy off)• bECMO and Vent settings adjusted to maintain
normal hemodynamics
Quadrox & Ventilator
Patient ManagementbECMO
• Saw IMMEDIATE improvement in patient’s hemodynamics and ventilation.
• Transferred to CCU with an open chest
BLENDER
H/C
IKUS
OXY
Patient Management23 Day Odyssey Begins
Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13
Day 14 Day 15 Day 16 Day 17 Day 23
Week 1
Week 2
Week 3
bECMOQ=0.6LPMIn-houseCCP 24/7
Charting q 2 hr
bECMOQ=0.7LPM
Sweep=1LPMFiO2=70%
Sweep Off thru OxyCCPs NOT in house
Oxy#2 AddedIn-houseCCP 24/7
Charting q 2 hr
Both PumpsChanged Out
Oxy NOT ChangedClot Inflow Oxy
RVAD Clot
CCPs & ECMOStaffing
7a-7p CCPs7p-7a ECMO
Chest ClosedNo ∆ bECMO
Begin ↓ SweepFiO2 21%
StableH Tx!!
Sm ClotInflowOxy
Oxy RemovedBerlin Only
bECMOQ= 0.8 LPM
Sweep=1LPMFiO2=50%
↑TrainingRNs & ECMO
Oxy #2 RemovedBerlin Only
Day 65 Discharged!
Time Line
bECMO ChallengesPersonnel Logistics
• 15 ECMO Specialists & 4 CCPs• Perfusion was in house 24/7 without
interruption to the OR schedule• Recap:
• Days 0-4 (CCPs 24/7)• Days 5-6 (break)• Days 7-13 (CCPs 24/7)
bECMO Challenges
Personnel Logistics
• CCPs in-house NOT bedside• CCPs checked every 2 hours.• Dilemma:
• ECMO team was not familiar with the Berlin.
• Perfusion had limited experience with Quadrox.
• Bedside nurse accustomed to 24/7
bedside ECMO Specialist.
bECMO ChallengesPersonnel Logistics• Solution:
• Training – ECMO team & CCU RNs
• Days 14 – 17 Shared Staffing with ECMO Specialists
• Perfusion 7a.m. to 7 p.m.• ECMO specialist 7p.m. to 7 a.m.
It Took a Village!
bECMO ChallengesCircuitry• Question: Why didn’t we use two circuits:
Berlin + V-V ECMO?• Answer: Real Estate: how to cannulate• Other concerns:
• Possibly needing very long-term support to H Tx• Preserving end organ function w/ pulsatillity (saw
on arterial pressure line tracing and pulse oximetry monitor)
bECMO ChallengesCircuitry Insight• Quadrox pedi ¼ inch connections• 10mL Berlin pumps ¼ inch connections• Made the slice easy• Larger Berlin pumps take 3/8 inch
connections
bECMO ChallengesAnticoagulation
• Didn’t use Berlin’s Anticoag Protocols because we had the Quadrox in circuit
• Used heparin & continuous AT3 infusion• Measured unfractionated heparin levels• TEG & Platelet mapping
bECMO ChallengesAnticoagulation• Hematology rounded daily• TEG “Learning Curve”; establishing protocols• Poor correlation w/ standard coag tests• Ran Unfractioned Heparin levels lower (0.1-0.3)
than normal range (0.3-0.7) to prevent bleeding• Completely turn heparin off to ↓ bleeding• (?) Was this due to BTHS• N=7 Berlins: all pt’s coag’s were different
bECMO ChallengesKey Learnings
• A very involved Hematology Team that understands TEG, PLT mapping and PLT aggregation is vital.
• Communication between disciplines is essential.
• Training is critical.• Patience, patience, patience.
Conclusion
Don’t be afraid to think “outside the box”
• Be Safe• Be Creative• Be Innovative
It just may …
Save a patient’s life!
ThanksbECMO is a “team sport”
• Great Cincinnati team of perfusionists, ECMO specialists, RNs, and doctors
• Colleagues around country helped via e-mail and phone
Discussion