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ECMO: 40 Years Later

Daneshmand, Mani A.; Milano, Carmelo A.

doi: 10.1097/MAT.0000000000000712
Invited Commentary

From the General and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.

Submitted for consideration October 2017; accepted for publication in revised form October 2017.

Disclosure: The authors have no conflicts of interest to report.

Correspondence: Carmelo A. Milano, Duke University Medical Center, Durham, NC 27710. Email: Carmelo.milano@duke.edu

The November–December 2017 issue of ASAIO Journal is home to five manuscripts on extracorporeal membrane oxygenation (ECMO). As we read the account of the first neonatal ECMO survivor Esperanza,1 we wondered whether in 1975, while reading the rejection of his original case report, Dr. Bartlett could even imagine a day when a major medical journal was routinely publishing on this subject. Esperanza, true to her name (Spanish for Hope), revived ECMO therapy and ECMO research at a time when because of multiple gross failures, the therapy was nearing extinction. Despite more than 40 years of progress, it is obvious that the major questions around ECMO therapy in 1975 and 2017 are the same. We are still trying to understand what is the best way to anticoagulate, ventilate, and cannulate these patients. We still do not know who will survive and who will have devastating neurological complications. As Drs. Huesch and Brehm2 clearly state in their call to arms, the time is neigh for collaborative, multi-institutional registry-based analyses of the relevant questions surrounding ECMO therapy. In the last 10 years, there has been an exponential increase in the number of publications on ECMO (Figure 1), but how much new knowledge have we gained?

Figure 1

Figure 1

The remaining manuscripts in this issue of the Journal attempt to address important problems within the ECMO community, specifically who are good candidates for extracorporeal cardiopulmonary resuscitation (eCPR), how should we ventilate patients on ECMO, and why do some patients have neurologic complications? To answer the first question, Conrad et al3 look to the Extracorporeal Life Support Organization database. They found that younger patients and myocarditis diagnosis were the best predictors for survival with eCPR, and predictably sepsis patients, persistently acidotic patients, and those with neurological complications while on support had the worst outcomes. Unfortunately, it is difficult to apply these findings broadly as almost 50% of the patients were treated before 2007, and all of them were treated before 2012. In the last 10 years, there have been considerable advances in both ECMO technology and heart replacement therapies. In our institution, a considerable proportion of our eCPR patients are cannulated after myocardial infarction. Although ECMO bridging remains one of the strongest predictors of morbidity and mortality after durable LVAD implantation, many of these patients, in the current era, are bridged successfully.

In a separate manuscript, Anton-Martin et al4 review their contemporary (2009–2014) institutional experience with pediatric ECMO patients who have a neurological complication. They carefully reported on well-matched cohorts of patients with and without neurological complications in an effort to describe laboratory differences amongst them. Contrary to other small studies, there were no laboratory differences among these groups.

Finally, Jenks et al5 surveyed the international community to understand the current trends in airway and ventilator management of patients on ECMO. The authors’ survey was returned by 144 centers (34.2% of those surveyed) throughout the world. This survey demonstrated a wide range of practices among the respondents. It is astonishing how disparate even the definition of “rest” ventilator settings is at ECMO centers.

Ultimately, after reviewing these five manuscripts, it is clear that Huesch and Brehm have hit the nail on the head. As we come up on the 50th anniversary of Dr. Hill’s first adult ECMO patient and while we reflect on Dr. Bartlett’s patient, as a community we have to unite and work toward answering the relevant questions. Participating in Extracorporeal Life Support Organization’s database by providing timely, accurate data is the first step in that process. The next step is to go back to our roots. ECMO started in the basic science lab; we must stop resting on our laurels and return to the lab to answer our questions and improve our therapies. Today, the biggest hurdles for our ECMO patients are neurologic injury, hematologic injury, blood compatibility, and organ recovery. None of these problems will be solved in the ward. If payers and policy makers are serious about improving patient care and preserving the life of those in extremis, then there needs to be a serious push towards funding fundamental research on organ injury and recovery. In a world where Google and Amazon know what we want seemingly before even we do, it is embarrassing that despite more than 40 years of progress and patients, we still struggle to answer the same fundamental questions as posed by Dr. Bartlett in 1975.

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References

1. Bartlett RH. Esperanza: the first neonatal ECMO patient. ASAIO J, 2017.63: 832–843.
2. Huesch M, Brehm C. The challenges in predicting ECMO survival, and a path forward. ASAIO J, 2017.63: 847–848.
3. Conrad S, Bridges B, Kalra Y, Pietsch J, Smith A. Extracorporeal cardiopulmonary resuscitation among patients with structurally normal hearts. ASAIO J, 2017.63: 781–786.
4. Anton-Martin P, Journeycake J, Modem V, Golla S, Raman L, Tweed J, Darnell-Bowens C. Coagulation profile is not a predictor of acute cerebrovascular events in pediatric ECMO patients. ASAIO J, 2017.63: 793–801.
5. Jenks CL, Tweed J, Gigli KH, Venkataraman R, Raman L. An international survey on ventilator, tracheostomy, and extubation practices among extracorporeal membrane oxygenation centers. ASAIO J, 2017.63: 787–792.
Copyright © 2017 by the American Society for Artificial Internal Organs