Extracorporeal life support devices and strategies for management of acute cardiorespiratory failure in adult patients: a comprehensive review

Evolution of extracorporeal life support (ECLS) technology has added a new dimension to the intensive care management of acute cardiac and/or respiratory failure in adult patients who fail conventional treatment. ECLS also complements cardiac surgical and cardiology procedures, implantation of long-term mechanical cardiac assist devices, heart and lung transplantation and cardiopulmonary resuscitation. Available ECLS therapies provide a range of options to the multidisciplinary teams who are involved in the time-critical care of these complex patients. While venovenous extracorporeal membrane oxygenation (ECMO) can provide complete respiratory support, extracorporeal carbon dioxide removal facilitates protective lung ventilation and provides only partial respiratory support. Mechanical circulatory support with venoarterial (VA) ECMO employed in a traditional central/peripheral fashion or in a temporary ventricular assist device configuration may stabilise patients with decompensated cardiac failure who have evidence of end-organ dysfunction, allowing time for recovery, decision-making, and bridging to implantation of a long-term mechanical circulatory support device and occasionally heart transplantation. In highly selected patients with combined severe cardiac and respiratory failure, advanced ECLS can be provided with central VA ECMO, peripheral VA ECMO with timely transition to venovenous ECMO or VA-venous ECMO upon myocardial recovery to avoid upper body hypoxia or by addition of an oxygenator to the temporary ventricular assist device circuit. This article summarises the available ECLS options and provides insights into the principles and practice of these techniques. One should emphasise that, as is common with many emerging therapies, their optimal use is currently not backed by quality evidence. This deficiency needs to be addressed to ensure that the full potential of ECLS can be achieved.

[1]  T. Welte,et al.  Bridge to Thoracic Organ Transplantation in Patients with Pulmonary Arterial Hypertension Using a Pumpless Lung Assist Device , 2009, American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons.

[2]  V. Rajagopal,et al.  A novel percutaneous mechanical biventricular bridge to recovery in severe cardiac allograft rejection. , 2010, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[3]  Erik E. Abel,et al.  Fulminant Neisseria meningitidis: role for extracorporeal membrane oxygenation. , 2010, The heart surgery forum.

[4]  S. Lapinsky,et al.  Critically Ill patients with 2009 influenza A(H1N1) in Mexico. , 2009, JAMA.

[5]  J. Kellum,et al.  Bench to bedside review: Extracorporeal carbon dioxide removal, past present and future , 2012, Critical Care.

[6]  John F. Fraser,et al.  Biventricular Assist Devices: A Technical Review , 2011, Annals of Biomedical Engineering.

[7]  Diana Elbourne,et al.  Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial , 2009, The Lancet.

[8]  Babak Sarani,et al.  A Review of the Fundamental Principles and Evidence Base in the Use of Extracorporeal Membrane Oxygenation (ECMO) in Critically Ill Adult Patients , 2011, Journal of intensive care medicine.

[9]  A. Pavie,et al.  Venoarterial Extracorporeal Membrane Oxygenation Support for Refractory Cardiovascular Dysfunction During Severe Bacterial Septic Shock* , 2013, Critical care medicine.

[10]  M. Anile,et al.  Extracorporeal removal CO2 using a venovenous, low-flow system (Decapsmart) in a lung transplanted patient: a case report. , 2009, Transplantation Proceedings.

[11]  M. Cove,et al.  Central extracorporeal membrane oxygenation for septic shock in an adult with H1N1 influenza. , 2010, The Annals of thoracic surgery.

[12]  J. Zwischenberger,et al.  Improved survival in venovenous vs venoarterial extracorporeal membrane oxygenation for pediatric noncardiac sepsis patients: a study of the Extracorporeal Life Support Organization registry. , 2012, Journal of pediatric surgery.

[13]  M. Strueber.  Bridges to lung transplantation , 2011, Current opinion in organ transplantation.

[14]  Michael Bailey,et al.  Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. , 2009, JAMA.

[15]  Arthur S Slutsky,et al.  Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS , 2013, Intensive Care Medicine.

[16]  R. Thiagarajan.  Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation: Useful, but for whom? , 2011, Critical care medicine.

[17]  B. Graf,et al.  First experience with the ultra compact mobile extracorporeal membrane oxygenation system Cardiohelp in interhospital transport. , 2011, Interactive cardiovascular and thoracic surgery.

[18]  J. Fraser,et al.  To ventilate, oscillate, or cannulate? , 2013, Journal of critical care.

[19]  J. Navia,et al.  Extracorporeal membrane oxygenation with right axillary artery perfusion. , 2005, The Annals of thoracic surgery.

[20]  J. Fraser,et al.  ECMO – the clinician’s view , 2012 .

[21]  Sylvie Chevret,et al.  Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis. , 2013, American journal of respiratory and critical care medicine.

[22]  B. Meyns,et al.  Ventricular unloading with a miniature axial flow pump in combination with extracorporeal membrane oxygenation , 2006, Intensive Care Medicine.

[23]  S. Jaber,et al.  Prone positioning in severe acute respiratory distress syndrome. , 2013, The New England journal of medicine.

[24]  M. Strueber.  Extracorporeal support as a bridge to lung transplantation , 2010, Current opinion in critical care.

[25]  V. Ranieri,et al.  Tidal Volume Lower than 6 ml/kg Enhances Lung Protection: Role of Extracorporeal Carbon Dioxide Removal , 2009, Anesthesiology.

[26]  N. Chi,et al.  Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis , 2008, The Lancet.

[27]  E. Fan,et al.  Therapies for refractory hypoxemia in acute respiratory distress syndrome. , 2010, JAMA.

[28]  J. Zwischenberger,et al.  Wang-Zwische Double Lumen Cannula—Toward a Percutaneous and Ambulatory Paracorporeal Artificial Lung , 2008, ASAIO journal.

[29]  A. Rocchini,et al.  Decompression of the left atrium during extracorporeal membrane oxygenation using a transseptal cannula incorporated into the circuit* , 2006, Critical care medicine.

[30]  Robert L Kormos,et al.  Predictors of death and transplant in patients with a mechanical circulatory support device: a multi-institutional study. , 2008, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[31]  P. Nair,et al.  Retrieval of critically ill adults using extracorporeal membrane oxygenation: an Australian experience , 2011, Intensive Care Medicine.

[32]  R. Damiano,et al.  Axillary artery cannulation for extracorporeal membrane oxygenator support in adults: an approach to minimize complications. , 2003, The Journal of thoracic and cardiovascular surgery.

[33]  M. Cove,et al.  Clinical review: mechanical circulatory support for cardiogenic shock complicating acute myocardial infarction , 2010, Critical care.

[34]  Pascal Leprince,et al.  Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock* , 2008, Critical care medicine.

[35]  Nader Moazami,et al.  The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. , 2013, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[36]  C. Wrede,et al.  Extracorporeal pumpless interventional lung assist in clinical practice: determinants of efficacy , 2009, European Respiratory Journal.

[37]  A. Menkis,et al.  Minimally invasive left-heart decompression during venoarterial extracorporeal membrane oxygenation: an alternative to a percutaneous approach. , 2010, Interactive cardiovascular and thoracic surgery.

[38]  M. Antonelli,et al.  The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks , 2011, Intensive Care Medicine.

[39]  Arthur S Slutsky,et al.  High-frequency oscillation in early acute respiratory distress syndrome. , 2013, The New England journal of medicine.

[40]  W. Butt,et al.  Extracorporeal membrane oxygenation and sepsis. , 2007, Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine.

[41]  G. Bhat,et al.  Use of a single-circuit CentriMag® for biventricular support in postpartum cardiomyopathy , 2013, Perfusion.

[42]  Laura Rountree Smith.  January , 1890, The Hospital.

[43]  Susanna Price,et al.  Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). , 2011, JAMA.

[44]  Jens Gottlieb,et al.  Bridge to lung transplantation with the extracorporeal membrane ventilator Novalung in the veno-venous mode: the initial Hannover experience. , 2007, ASAIO journal.

[45]  Y. Toyoda,et al.  Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults. , 2010, The Annals of thoracic surgery.

[46]  R. Bartlett,et al.  Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era , 2012, Intensive Care Medicine.

[47]  D. Young,et al.  High-frequency oscillation for acute respiratory distress syndrome. , 2013, The New England journal of medicine.

[48]  Philip E. Johnson,et al.  Use of Extracorporeal Membrane Lung Assist Device (Novalung) in H1N1 Patients , 2011, Journal of cardiac surgery.

[49]  A. Bodenham,et al.  Pumpless extracorporeal carbon dioxide removal for life-threatening asthma , 2007, Critical care medicine.

[50]  R. Bartlett,et al.  Current status of extracorporeal life support (ECMO) for cardiopulmonary failure. , 2010, Minerva anestesiologica.

[51]  J. Prutkin,et al.  Percutaneous right ventricular assist device as support for cardiogenic shock due to right ventricular infarction. , 2008, The Journal of invasive cardiology.

[52]  A. Loundou,et al.  Neuromuscular blockers in early acute respiratory distress syndrome. , 2010, The New England journal of medicine.

[53]  Robert L Kormos,et al.  Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. , 2013, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[54]  D. Brodie,et al.  Extracorporeal membrane oxygenation for respiratory failure in adults , 2012, Current opinion in critical care.

[55]  Extracorporeal Membrane Oxygenation for 2009 Influenza A ( H 1 N 1 ) Acute Respiratory Distress Syndrome , 2009 .

[56]  J. Egan,et al.  The Novalung interventional lung assist as bridge to lung transplantation for self-ventilating patients - initial experience. , 2011, Interactive cardiovascular and thoracic surgery.

[57]  J. Navia,et al.  Outcomes of axillary artery side graft cannulation for extracorporeal membrane oxygenation. , 2013, The Journal of thoracic and cardiovascular surgery.

[58]  S. Donath,et al.  Central extracorporeal membrane oxygenation for refractory pediatric septic shock , 2011, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[59]  M. Meade,et al.  Critically ill patients with 2009 influenza A(H1N1) infection in Canada. , 2009, JAMA.

[60]  M. Massetti,et al.  From extracorporeal membrane oxygenation to ventricular assist device oxygenation without sternotomy. , 2013, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[61]  Robert H Bartlett,et al.  Extracorporeal Membrane Oxygenation Circuitry , 2013, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[62]  J. Fraser,et al.  Pharmacokinetic changes in patients receiving extracorporeal membrane oxygenation. , 2012, Journal of critical care.