Franco Valenza Department of Pathophysiology and Transplantation Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico New perspectives in ECMO 2012.

Franco Valenza

Department of Pathophysiology and Transplantation

Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico

New perspectives in ECMO 2012

ECMO and lung transplant program

No conflict of interest

New perspectives in ECMO 2012

ECMO and lung transplant program

New perspectives in ECMO 2012

ECMO and lung transplant program

Conventional

Un-conventional

ECMO - Bridge ECMO - PGDECMO - Support

Conventional

ECMO - Bridge ECMO - PGDECMO - Support

before during after

Lung Transplantation

ECMO - SupportECMO - Bridge ECMO - PGD

Hemodynamics

Hypoxia - Hypercapnia

Anticoagulation

Wen-Je, Artifical Organs (2001); 25(8):607

Bittner, Eur J Cardio Thor Surg (2007); 31: 462

Burdett, Inter CardioVasc Thor Surg (2012);15:432

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

# 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

# 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

ECMO - Bridge ECMO - PGDECMO - Support

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

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

ECMO - Bridge ECMO - Support ECMO - PGD

Postoperative “treatment” tool

Oto, Ann Thor Surg (2004);78:1230

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

McILwain, Lab Invest (2010);90:128

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

Valenza, un published

New perspectives in ECMO 2012

ECMO and lung transplant program

Conventional

Un-conventional

ECMO - Bridge ECMO - PGDECMO - Support

RECIPIENT

ECMO - Bridge ECMO - PGDECMO - Support

RECIPIENT

reverse - ECMO

LUNG DONOR

reverse - ECMOEx-Vivo Lung Perfusion (EVLP)

Cypel, NEJM (2011);364:1431

*

Valenza, Transpl Proc (2012); 44:1826-9

ECMO - Bridge ECMO - PGDECMO - Support

RECIPIENT

donor - ECMO

reverse - ECMO

LUNG DONOR

LUNG DONOR

Lung Harvest

Transplantation

BRAIN DEATH

Maastricht III

CARDIAC DEATH

EVLPMaastricht II

ECMO

Refractory cardiogenic shock

ECMOMaastricht VI

Liver OLTX

Rat Lungs

…. in conclusion

LUNG DONOR

RECIPIENTBridge

SupportPGD

EVLPDCD

No way I’m gonna stay with-out ECMO!

…. thanks for your attention!