Post on 03-Jun-2015
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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)
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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
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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.