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Table of Contents
LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 161-162
Heart and ECMO: Are we ready?


Department of Cardiology and Internal Medicine,Medwin Hospital, Nampally,Hyderabad, AP, India

Click here for correspondence address and email

Date of Web Publication25-May-2011
 

How to cite this article:
Gude D. Heart and ECMO: Are we ready?. Ann Card Anaesth 2011;14:161-2

How to cite this URL:
Gude D. Heart and ECMO: Are we ready?. Ann Card Anaesth [serial online] 2011 [cited 2019 Oct 19];14:161-2. Available from: http://www.annals.in/text.asp?2011/14/2/161/81578


The Editor,

Having read editorial 'ECMO - The way to go, [1] we wanted to share our observations on Extracorporeal membrane oxygenation (ECMO). ECMO has been shown to be instrumental in salvaging severe cardiorespiratory compromise especially in pediatric patients (related to myocarditis) although female gender, arrhythmia on ECMO and need for dialysis during ECMO may preclude a good prognosis. [2] Also in children with refractory septic shock central ECMO outperformed the conventional ECMO and documented a better survival rate. ECMO-CPR (ECPR) during cardiac arrest unresponsive to conventional CPR in children with cardiac disease promoted survival with favorable neurological outcomes. Metabolic acidosis, noncardiac structural or chromosomal anomalies, development of end-organ injury on ECMO and longer ECMO duration reflected higher mortality in these patients. Even among adults with in-hospital cardiac arrest (especially of cardiac origin), the survival discharge rate and 6-month survival rates with minimal neurological impairment in those receiving ECMO were significantly higher than that of conventional CPR (>10 minutes). [3]

Thrombosis and hemorrhage are amongst the most common adverse effects of ECMO. A study showed that either thrombosis or hemorrhage or both (in 31%) are seen in 86% of ECMOs. Other than congenital cardiac disease (which heightened susceptibility to thrombosis on ECMO), abnormal laboratory parameters like prothrombin time, partial thromboplastin time, platelet count, fibrinogen level, and activated clotting time have not demonstrated reliability in predicting thrombosis or hemorrhage (limitations due to consumptive coagulopathies, clotting factor deficiencies, platelet dysfunction, fibrinolysis etc). [4] In gauging the amount of unfractionated heparin (UFH) to be administered, monitoring anti-Xa UFH and antithrombin-III has proved more effective.

In patients on venoarterial ECMO post-cardiac surgery, mortality is shown to be lower in younger, nondiabetic patients with cardiogenic shock who had shorter cardio-pulmonary bypass times. ECMO has proven benefit in postcardiotomy shock but preoperative markers like poor left-ventricular ejection fraction, systolic blood pressure <90 mmHg and refractory severe metabolic acidosis hinder the ECMO wean off. Low albumin, low platelet count, low oxygen pressure of the venous tube of the ECMO and poor cardiac systolic function predict the peri-ECMO mortality. [5]

It has been shown that about half of the otherwise lethal cardiogenic shock patients in remote institutions can be rescued on emergent ECMO (with a Mobile Cardiac Remote Assist unit). In such a setting, the in-hospital mortality predictors are cardiac arrest, oligoanuria, inotrope score > 20 (summed rate of infusions of dopamine, dobutamine, and higher arbitrary rates of epinephrine and norepinephrine), higher pre-ECMO arterial lactate levels and dilated cardiomyopathy. On ECMO, the longer term survival (365 days) depends on factors like age, history of acute coronary syndrome and the presence of cardiac arrest before ECMO (early circulatory support with ECMO before cardiac arrest being beneficial). In severe Early Graft Failure (EGF) patients after cardiac transplantation, ECMO equates the one year conditional survival with those without EGF.

The indications for ECMO in the cardiac intensive unit are ever increasing and we agree with the editor that there is an urgent need for clinicians to embrace the awareness.

 
   References Top

1.Chakravarthy M. ECMO - the way to go. Ann Card Anaesth 2011;14:1-2.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Rajagopal SK, Almond CS, Laussen PC, Rycus PT, Wypij D, Thiagarajan RR. Extracorporeal membrane oxygenation for the support of infants, children, and young adults with acute myocarditis: A review of the Extracorporeal Life Support Organization registry. Crit Care Med 2010;38:382-7.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Chauhan S, Malik M, Malik V, Chauhan Y, Kiran U, Bisoi AK. Extra corporeal membrane oxygenation after pediatric cardiac surgery: a 10 year experience. Ann Card Anaesth 2011;14:19-24  Back to cited text no. 3
    
4.Reed RC, Rutledge JC. Laboratory and clinical predictors of thrombosis and hemorrhage in 29 pediatric extracorporeal membrane oxygenation nonsurvivors. Pediatr Dev Pathol 2010;13:385-92.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Hsu PS, Chen JL, Hong GJ, Tsai YT, Lin CY, Lee CY, et al. Extracorporeal membrane oxygenation for refractory cardiogenic shock after cardiac surgery: Predictors of early mortality and outcome from 51 adult patients. Eur J Cardiothorac Surg 2010;37:328-33.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Dilip Gude
AMC, 3rd Floor, Medwin Hospital,Chirag Ali Lane, Nampally,Hyderabad, AP- 500 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.81578

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