1. CAMPUS GROSSHADERN - HERZCHIRURGISCHE KLINIK UND POLIKLINIK HERZKLINIK AM AUGUSTINUM ECMO as Bridge to Lung Transplant – Ambulatory V/V&V/VA ECMO: How to do it & Building the Team Christian Hagl Department of Cardiac Surgery, University Hospital Munich (LMU), Germany Disclosure: The author declares no conflict of interest

2. Hannover Medical School Munich University Hospital 11/2011 Lung transplant program

3. Waiting list eurotransplant LAS

4. The rule of ECMO in transplantation Am J Respir Crit Care Med Vol 185, Iss. 7, pp 763–768, Apr 1, 2012

6. Technical Advances

7. The Munich Experience

8. Staff and organization (respiratory failure) Department of Anesthesiology Medical Department I/ Pneumology Department of Cardiac Surgery Department of Thoracic Surgery

9. Department of Cardiac Surgery Medical Department I (Cardiology) Heart Team Staff and organization (cardiac failure)

10. MUNICH ECMO/ECLS Network Physicians Nurses Perfusionists Scrub nurses Transport specialists Special transporta tion ICU +

11. CAMPUS GROSSHADERN CAMPUS INNENSTADT LOREM IPSUM SETUR ALARME In-house ECMO/ECLS Logistics + Implementation In-house ECMO/ECLS Logistics + Implementation

12. Herzchirurgische Klinik an der LMU Herzklinik am Augustinum KLINIKUM DER UNIVERSITÄT MÜNCHEN ® in-house call ECLS Implantation by cardiac surgeon and perfusionist alarm approx.: 200 x year (Cardiac surgeon at ICU) locations: cathlab, emergency room and Intensive Care Unit

13. Herzchirurgische Klinik an der LMU Herzklinik am Augustinum KLINIKUM DER UNIVERSITÄT MÜNCHEN ® Content of emergency trolley: v-a cannulas in all sizes, Seldinger guide wires, material, etc. ICU emergency room cathlab nursing unit in-house equipment for ECLS implantation Clinic goes to patient

14. Herzchirurgische Klinik an der LMU Herzklinik am Augustinum KLINIKUM DER UNIVERSITÄT MÜNCHEN ® Decision making process after ECLS implantation Heart Team

15. Herzchirurgische Klinik an der LMU Herzklinik am Augustinum KLINIKUM DER UNIVERSITÄT MÜNCHEN ® in-house call ECMO Anesthesiologist or cardiac surgeon and perfusionist alarm approx.: 100 x year (anesthesiologist at the ICU) locations: Intensive Care Unit Decision for implantation in transplant candidates

16. CAMPUS GROSSHADERN CAMPUS INNENSTADT LOREM IPSUM SETUR ALARME External ECLS/ECMO Logistics + Implementation External ECLS/ECMO Logistics + Implementation

17. Herzchirurgische Klinik an der LMU Herzklinik am Augustinum KLINIKUM DER UNIVERSITÄT MÜNCHEN ® external emergency call (ECMO/ECLS) request to the attending senior physician doc to doc conversation implantation in external hospitals by experienced ECLS team (ECLS: cardiac surgeon + perfusionist) (ECMO: anesthesiologist or cardiac surgeon + perfusionist) Transport by cardiac surgeon +/- anesthesiologist + perfusionist

18. Herzchirurgische Klinik an der LMU Herzklinik am Augustinum KLINIKUM DER UNIVERSITÄT MÜNCHEN ® transport equipment content emergency trolley: v-a cannulas in all sizes Seldinger guide wire, ACT messurement, material, etc. technical requirements 24/7 out-side use

19. Herzchirurgische Klinik an der LMU Herzklinik am Augustinum KLINIKUM DER UNIVERSITÄT MÜNCHEN ® upward4 G foreward16 G sideward8 G downward20 G backward1.5 G specifications of grafity – load direction european aviation savety agency EASA, www.easa.europa.euwww.easa.europa.eu Heart Lung Renal Assist

22. The clinic to go.

23. V-V ECMO in hypoxemic or hypercapnic respiratory failure V-A ECMO in right ventricular failure or profound hypoxemia Awake ECMO preferred when possible Comfort oriented cannulation (e.g. Avalon cannula) Choice of ECMO procedure in potential Ltx pts

24. WHEN? Bridge to Lung Transplant Refractory hypercapnic and/or hypoxic respiratory failure: paCO 2 >80 mmHg and/or PaO 2 /FiO 2 <80 mmHg despite maximum noninvasive support Right ventricular failure refractory to prostacyclin treatment and catecholamines with secondary organ dysfunction Young patients, absence of multi-organ dysfunction, good prospects for rehabilitation after LTx

25. The Munich Experience n 11/2011-12/2014 Age 50+/-14 years, 39% female 65% 71.1% 23.8%

26. The Munich Experience V/V&V/A ECMO/ELCS as Bridge to LTx Weig et al. Clin Transplant 2013

27. Goals for a sucessful ambulatory ECMO/ECLS program Competence center Trouble shooting concepts Definition of minimum acceptable volume Decision making rules Adaequate funding and reimbursement Political support Highly motivated staff Frequent training and education Interdisciplinary thinking Data base registrations Ethics

28. WHEN? (Relative) contraindications Multi-organ-failure Neurological deficit/unclear neurological situation Bleeding Malignancy (Severe arterial occlusive disease) (HIT type II) (Septic shock) Absolute contraindications? Decision on individual basis