Transcript ECMO and lung transplant program

New perspectives in ECMO 2012
ECMO and lung transplant program
Franco Valenza
Department of Pathophysiology and Transplantation
Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
New perspectives in ECMO 2012
ECMO and lung transplant program
No conflict of interest
New perspectives in ECMO 2012
ECMO and lung transplant program
Conventional
Un-conventional
Conventional
ECMO - Bridge
ECMO - Support
ECMO - PGD
Lung Transplantation
before
during
after
ECMO - Bridge
ECMO - Support
ECMO - PGD
Anticoagulation
Hemodynamics
Hypoxia - Hypercapnia
ECMO - Bridge
ECMO - Support
ECMO - PGD
Wen-Je, Artifical Organs (2001); 25(8):607
Bittner, Eur J Cardio Thor Surg (2007); 31: 462
Burdett, Inter CardioVasc Thor Surg (2012);15:432
ECMO
Pre
Intra
Post
RBC
FFP
1
Bil
Yes
VV (6)
VV
VV (1)
7
4
2
Bil
Yes
VV (6)
VA
VV (2)
21
28
3
Bil
3
3
2
0
3
2
4
PLT
Redo
2
5
Bil
Yes
6
Bil
Yes
VV (4)
VV
VV (1)
8
8
1
7
Bil
Yes
VV (3)
VA
VV (5)
19
28
2
Yes
8
Bil
9
Bil
24
5
Yes
3
Yes
VA
Bleeding
Yes
Yes
2
Yes
VA
10
Yes
VV
11
Yes
VA
12
Yes
VV (9)
VA
32
5
VV (1)
28
30
13
2
1
14
1
15
16
Bil
3
6
17
Bil
5
4
18
4
19
20
Ca’ Granda, from 3/2011 to present
#
RBC
FFP
ECMO
no ECMO
9
11
8 (1-24)
2 (0-3) *
0.038
14 ± 13
1±2*
0.004
VA
VV
6
3
17 ± 13
5±4
0.171
19 ± 13
4±4
0.083
VA + bridge
VA
3
3
22 ± 5
12 ± 18
0.356
29 ± 1
10 ± 12
0.057
#
RBC
FFP
ECMO
no ECMO
9
11
8 (1-24)
2 (0-3) *
0.038
14 ± 13
1±2*
0.004
VA
VV
6
3
17 ± 13
5±4
0.171
19 ± 13
4±4
0.083
VA + bridge
VA
3
3
22 ± 5
12 ± 18
0.356
29 ± 1
10 ± 12
0.057
ECMO - Bridge
ECMO - Support
ECMO - PGD
ECMO Bridge Lung Transplantation
Pub Med search
20
Lang, Transplantation (2012);93:729
Bittner, Ann Thor Surg (2012);94:942
n. of references
15
10
5
0
1990
1995
2000
Year
2005
2010
ECMO Bridge Lung Transplantation
Pub Med search
20
Awake vs.Intubated
Ambulatory ECMO bridge
n. of references
15
Early vs. Late
10
5
0
1990
1995
2000
Year
2005
2010
ECMO - Bridge
ECMO - Support
ECMO - PGD
Postoperative “treatment” tool
Oto, Ann Thor Surg (2004);78:1230
Intraoperative “prevention” tool
Low perfusion pressure
Bhabra, Ann Thor Surg 1996;61:1631
Bhabra, Ann Thor Surg 1998;65:187
Pierre, J Thorac Cardiovasc Surg 1998;116:932
Clark, J Thorac Cardiovasc Surg 1998;115:1335
Halldorsson, J Thorac Cardiovasc Surg 1998;115:415
Protective ventilation
De Perrot, J Thorac Cardiovasc Surg 2002;124:1137
Crimi, Am J respir Crit Care Med 2005;174:178
Chiang, Resuscitation 2008;79:147
Valenza, Organ Tissue & Cells (2012)
McILwain, Lab Invest (2010);90:128
70
4
MCP-1
CXCL-10
*
60
3
50
40
2
30
20
Relative expression
1
10
0
0
Control
BD
Ischemia
BD
Ischemia
Graft
1.8
20
18
Control
Graft
IL-8
16
*
1.6
*
HMGB-1
1.4
14
1.2
12
1.0
*
10
0.8
8
0.6
6
0.4
4
0.2
2
0.0
0
Control
BD
Ischemia
Graft
Control
BD
Ischemia
Graft
Valenza, un published
Valenza, un published
New perspectives in ECMO 2012
ECMO and lung transplant program
Conventional
Un-conventional
ECMO - Bridge
ECMO - Support
RECIPIENT
ECMO - PGD
LUNG DONOR
reverse - ECMO
ECMO - Bridge
ECMO - Support
RECIPIENT
ECMO - PGD
reverse - ECMO
Ex-Vivo Lung Perfusion (EVLP)
Cypel, NEJM (2011);364:1431
*
Valenza, Transpl Proc (2012); 44:1826-9
LUNG DONOR
donor - ECMO
reverse - ECMO
ECMO - Bridge
ECMO - Support
RECIPIENT
ECMO - PGD
Maastricht VI
Refractory
cardiogenic shock
ECMO
Liver OLTX
LUNG DONOR
BRAIN DEATH
CARDIAC DEATH
Rat Lungs
Maastricht III
Lung Harvest
EVLP
Transplantation
Maastricht II
ECMO
…. in conclusion
No way I’m gonna stay with-out ECMO!
RECIPIENT
EVLP
DCD
LUNG DONOR
Bridge
Support
PGD
…. thanks for your attention!