Neonatal ECMO Chris Burke MD March 6, 2014

Basics Types Requires systemic anticoagulation Veno-arterial (VA): full cardiopulmonary support Veno-venous (VV): pulmonary support only Requires systemic anticoagulation Perfusionist necessary to operate pump; differential flows allow for maximal support/weaning Multiple complications exist: access site issues, bleeding, HIT, and thrombus formation

Types VA VV

History of ECMO

History of ECMO John Gibbon credited with the first use of a prosthetic heart-lung machine for cardiac surgery in 1953 Early CPB was lethal after several hours Kolobow, Bartlett, and others demonstrated that extracorporeal circulation of the blood could be carried out for days or weeks without toxicity or hemolysis, as long as direct blood-gas contact was avoided

History of ECMO First successful ECMO case was in 1972 in San Francisco Bartlett and his team performed first neonatal ECMO case in 1975 at UC-Irvine Bartlett then moved to the University of Michigan, establishing the first neonatal ECMO program in 1980 The extracorporeal life support organization (ELSO) is formed in 1989

Bartlett et al 1985 Bartlett and his team had established safety of ECMO with case series in the late 1970s and early 1980s In infants with birth weight greater than 2kg, survival on ECMO was 70%; in contrast to a 20% survival rate for infants treated with best medical management The stage was set for the first randomized “phase 2” trial in neonates

Bartlett et al 1985 Trial utilized a unique, “randomized play-the-winner” design Neonates greater than 2kg with a greater than 90% chance of demise were selected for the trial

Bartlett et al 1985 During the 18 months of enrollment, 12 patients were ultimately randomized 1 neonate in the control group; 11 in the ECMO cohort Conventional treatment included maintaining PaO2 70-150 mmHg, hyperventilation +/- bicarb infusion to maintain PaCO2 < 35 mmHg and pH > 7.5

Bartlett et al 1985

Bartlett et al 1985 Control patient died of progressive respiratory failure 13 days after randomization

Bartlett et al 1985 Unique study design, but laid the ground-work for ECMO becoming routine in critically ill neonates Long-term sequela were unknown Four children went on to have developmental delay or mild neurologic problems This trial and other early reports led to the establishment of several ECMO programs throughout the US

Low Birth Weight Infants

LBW Infants Many guidelines suggest that ECMO may not be safe for neonates less than 2kg Early reports in LBW infants revealed a nearly 80% mortality rate in this cohort Concern over hemorrhagic complications, notably intracranial hemorrhage

LBW Infants Authors sought to challenge the idea that ECMO is not safe in infants less than 2kg Utilized the ELSO registry to obtain data on 14,305 neonates placed on ECMO between 1991-2002 13,642 HBW (greater than 2 kg) 663 LBW (less than 2 kg)

LBW Infants

LBW Infants

LBW Infants Though survival in LBW infants is lower, it is still 53%, which is similar to the rate in older patients after cardiac failure and may be higher than the expected outcome if ECMO were not used in these cases Infants weighing 1.6kg or more have an expected ECMO survival of 40% Fatal bleeding more common in LBW infants more conservative anticoagulation strategy needed? Selection bias may be present limitation of registry study

Long-term Outcomes

Jaillard et al 2000 Single center retrospective review sought to evaluate long-term outcomes in neonatal ECMO All cases of ECMO reviewed from Oct 1991-Sep 1997 Infants were followed with serial neurodevelopmental, respiratory, and digestive evaluations

Jaillard et al 2000 57 infants enrolled in the study CDH (n=23), sepsis (n=14), MAS (n=12), others (n=8) Mean time of onset was 70 h Mean duration of ECMO was 134 h

Jaillard et al 2000 Survival at two-years was 40/57 (70%) CDH 52%, NS 79%, MAS 100%, others 62% Ten neonates died on ECMO Five technical complications were noted on ECMO Pump malfunction (2), air in circuit (1), hemorrhage (1), heat exchanger malfunction (1)

Jaillard et al 2000 Two infants with clinical vision anomalies; one infant with severe hearing loss requiring prosthesis 45% of infants were oxygen-dependent at 28 days (83% CDH) Four infants required tracheostomy (all CDH) Two infants were O2 dependent at two-years (both CDH) Growth retardation in 12 infants; GERD noted in 11 Four required G-tube (all CDH) 95% of carotid reconstructions were patent at two-years

Jaillard et al 2000 Survival was high in all groups with limited morbidity; however, CDH infants fared worse than their counterparts All carotid arteries were reconstructed with good anatomic outcome Neonates with CDH remain a significant challenge

Congenital Diaphragmatic Hernia

CDH Between 20-40% of infants with CDH require ECMO rescue therapy VA ECMO has traditionally been the predominant form in CDH VV ECMO has several advantages Spares ligation of the carotid artery Minimizes embolic risk to the brain Perfusion of the pulmonary vasculature Maintenance of pulsatile flow

VV vs. VA Disease-severity risk-adjusted analysis of VV and VA ECMO outcomes in CDH Utilized the ELSO database (1991-2006) Primary outcome was in-hospital mortality; secondary outcomes included complication rates

VV vs. VA

VV vs. VA

VV vs. VA No differences in the risk-adjusted odds of mortality between infants with CDH undergoing VV vs. VA ECMO [46% vs 50%, p=.03] Echocardiographic data was excluded from this analysis 18% conversion rate from VV to VA ECMO; this carried a 56% mortality rate VV ECMO may be a feasible option in infants with CDH