J Thorac Cardiovasc Surg 2008;135:717-718
© 2008 The American Association for Thoracic Surgery
Reply to the Editor
Ranjit John, MD
Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN 55455
I appreciate the comments of Santise and colleagues regarding the role of extracorporeal membrane oxygenation (ECMO) in the care of patients with refractory cardiogenic shock. Clearly, ECMO has been, and will probably always remain, a useful treatment in the ever-changing armamentarium options for this critically ill group. It is still the primary option for pediatric patients, but the frequency of its use for adults has been significantly reduced thanks to improved short-term ventricular support devices (eg, CentriMag, Abiomed). Such devices provide more reliable support, with markedly improved durability with respect to the Bio-Medicus systems, the first generation of short-term ventricular assist devices.
ECMO certainly offers the advantage of avoiding a median sternotomy, as well as the opportunity for rapid institution of support in the catheterization laboratory and the intensive care unit, as Santise and colleagues report. The use of ECMO is limited, however, by its main drawbacks: limited durability and significant neurologic and peripheral vascular complications. The incidence of such complications may be affected by technologic advances in the design of ECMO circuits and oxygenators or by altered peripheral cannulation techniques. Several published studies, some involving pediatric patients, have looked at the use of ECMO for a wide range of indications (eg, graft failure after lung transplantation, right ventricular failure after heart transplantation, postcardiotomy assistance, resuscitation after cardiac arrest, and bridge to bridge support for cardiogenic shock). All these series reported a mean ECMO duration of about 4 days or less.1-5
In one large, experienced single-center series, the complications during ECMO were as follows: infectious, 49%; renal failure requiring dialysis, 40%; neurologic, 33%; and limb complications, 25%.2 Of course, not all such complications are related to ECMO itself. Instead, they often are a result of the critical condition of a patient with multiorgan dysfunction. Further, all such complications (with the relative exception of limb complications) can also potentially occur with short-term ventricular assist devices.
In conclusion, I agree with Santise and colleagues that there is definitely a place for ECMO in the treatment of patients with acute cardiogenic shock. In the near future, we do not know what the interplay will be between surgical and percutaneous devices, including ECMO. Until then, it remains imperative that we continue to be innovative, open-minded, and aggressive, continually striving to improve outcomes for this critically ill group of patients.
References
- Pagani FD, Lynch W, Swaniker F, Dyke DB, Bartlett R, Koelling T, et al. Extracorporeal life support to left ventricular assist device bridge to heart transplant: a strategy to optimize survival and resource utilization. Circulation 1999;100(19 Suppl):II206-II210.[Medline]
- Smedira NG, Moazami N, Golding CM, McCarthy PM, Apperson-Hansen C, Blackstone EH, et al. Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: survival at 5 years. J Thorac Cardiovasc Surg 2001;122:92-102.[Abstract/Free Full Text]
- Alsoufi B, Al-Radi OO, Nazer RI, Gruenwald C, Foreman C, Williams WG, et al. Survival outcomes after rescue extracorporeal cardiopulmonary resuscitation in pediatric patients with refractory cardiac arrest. J Thorac Cardiovasc Surg 2007;134:952-959.[Abstract/Free Full Text]
- Meyers BF, Sundt TM, Henry S, Trulock EP, Guthrie T, Cooper JD, et al. Selective use of extracorporeal membrane oxygenation is warranted after lung transplantation. J Thorac Cardiovasc Surg 2000;120:20-28.[Abstract/Free Full Text]
- Magovern Jr. GJ, Simpson KA. Extracorporeal membrane oxygenation for adult cardiac support: the Allegheny experience. Ann Thorac Surg 1999;68:655-661.[Abstract/Free Full Text]
