1. LABORATORY OF BIOLOGICAL STRUCTURE MECHANICS www.labsmech.polimi.it Technical and biological advances in ECMO New Perspective in ECMO 2012 III International Meeting Milan, 5 October 2012 Maria Laura Costantino

2. ECMO is the use of a modified extracorporeal circuit to provide temporary mechanical support (respiratory and/or cardiac) to patients failing conventional intensive therapy. ECMO has brought the technology of cardiopulmonary bypass to bedside under the management of ECMO specialists and intensive care physicians. Extracorporeal Membrane Oxygenation(ECMO)

3. Maria Laura Costantino History 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system.

4. Maria Laura Costantino Dr & Mrs Gibbon with their CPB machine History 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system.

5. Maria Laura Costantino History 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system. 1950 – Early Developements of CPB. 1956 – GHA Clowes Jr. – Plastic Membrane Oxygenator. 1957 – K Kammermeyer – Use of thin Silicone Membranes. Early ’60s – T Kolobow designed his “Membrane Lung”. 1972 – JD Hill reported first successful case of prolonged extracorporeal support in humans: Adult ECMO

6. Maria Laura Costantino History

7. Maria Laura Costantino 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system. 1950 – Early Developements of CPB. 1956 – GHA Clowes Jr. – Plastic Membrane Oxygenator. 1957 – K Kammermeyer – Use of thin Silicone Membranes. Early ’60s – T Kolobow designed his “Membrane Lung”. 1972 – JD Hill reported first successful case of prolonged extracorporeal support in humans: Adult ECMO 1975 – RH Bartlett - First Successful Neonatal ECMO 1986 – L Gattinoni - 50% Survival in Adult ECCO 2 R 1989 – ELSO Registry History

8. Maria Laura Costantino 1917 – J Mac Lean discovered Heparin (which was introduced in clinical practise in 1938). 1930 – JH Gibbon - First extracorporeal circulation system. 1950 – Early Developements of CPB. 1956 – GHA Clowes Jr. – Plastic Membrane Oxygenator. 1957 – K Kammermeyer – Use of thin Silicone Membranes. Early ’60s – T Kolobow designed his “Membrane Lung”. 1972 – JD Hill reported first successful case of prolonged extracorporeal support in humans: Adult ECMO 1975 – RH Bartlett - First Successful Neonatal ECMO 1986 – L Gattinoni - 50% Survival in Adult ECCO 2 R 1989 – ELSO Registry History From then on, over and over increasing number of centres are performing either adult or neonatal ECMO

9. Maria Laura Costantino The type of ECMO depends on the patient’s underlying cardiac function. Provides support for severe respiratory failure when reasonable heart function is assessed. Induces low hemodynamic disturbances. 1 or 2 access cannulae can be used depending on the bypassed blood flow. Provides support for severe cardiac and respiratory failure, most commonly after cardiac surgery. Induces high hemodynamic disturbances depending on the chosen return access sites. Can be used as a bridge to cardiac recovery or to another destination therapy. Veno-Venous (V-V) ECMO Veno-Arterial (V-A) ECMO ECMO Types

10. Maria Laura Costantino ECMO Types Second Access Cannula SVC Return Cannula IVC Access Cannula IVC Return Cannula FA Access Cannula FV Veno-Venous (V-V) ECMO Veno-Arterial (V-A) ECMO

11. Maria Laura Costantino ECMO Circuit Outflow cannula Inflow cannula Pump Oxygenator Lines Equipment Main Issues Efficacy Priming Volume Haemolysis Compatibility Duration Membrane Lung Pump Gas Source Patient

12. Maria Laura Costantino ECMO main technical advances are in 4 areas 1) A move from VA to VV ECMO: helped by the widespread use of a wide size range of double-lumen veno-venous cannulae. Return (arterial) lumen Outflow (venous) lumen DL VV catheter

13. Maria Laura Costantino ECMO main technical advances are in 4 areas 1)A move from VA to VV ECMO: helped by the widespread use of a wide size range of double-lumen veno-venous cannulae. 2)A move from roller to centrifugal pumps that do not damage the red cells (most main pump manufacturers have systems). Roller Pump Head Centrifugal Pump Head Centrifugal Pump Console Roller Pump Console Centrifugal Pump Drive Unit

14. Maria Laura Costantino ECMO main technical advances are in 4 areas 1)A move from VA to VV ECMO: helped by the widespread use of a wide size range of double-lumen veno-venous cannulae. 2)A move from roller to centrifugal pumps that do not damage the red cells - most main pump manufacturers have systems. 3)A switch from silicone membrane oxygenators to polymethylpentene hollow fibre ones. Silicone membrane oxygenator unravelled

15. Maria Laura Costantino ECMO main technical advances are in 4 areas 1)A move from VA to VV ECMO: helped by the widespread use of a wide size range of double-lumen veno-venous cannulae. 2)A move from roller to centrifugal pumps that do not damage the red cells - most main pump manufacturers have systems. 3)A switch from silicone membrane oxygenators to polymethylpentene hollow fibre ones. 4)Miniturisation of circuits: all the above have allowed circuit miniturisation, have facilitated transport on ECMO and have allowed us to run with much less Heparin, thus reducing bleeding risk.

16. Maria Laura Costantino Thank you for your attention 16