Preface

Chapter 7 **Mechanical Circulatory Support (MCS) for Primary Graft**

Chapter 8 **Extracorporeal Membrane Oxygenation Support for Post-**

Luiz Fernando Caneo and Vitor Barzilai

**Cardiotomy Cardiogenic Shock 107**

Chapter 9 **Use of ECMO in Sepsis and Septic Shock 119**

Chapter 10 **Education Curriculum on Extracorporeal Membrane**

**CPB Console: 23 Years' Experience 149**

Marroquín and Jorge Luis Cervantes-Salazar

Chapter 13 **Flow Optimization, Management, and Prevention of LV**

**Distention during VA-ECMO 183**

**Support: Recent Advances 213**

Faruk Özalp and Stephan Schueler

**Oxygenation: The Evolving Role of Simulation Training 135** Simon Sin Wai Ching, Pauline Yeung Ng, Wallace Ngai Chun Wai, Peter Lai Chi Keung, Ricky Chan Wai Kit and Andy Mok Yuen Tin

Umberto Borrelli, Marc Detroux, Remi Nottin, Stephane Nikis and

Cristiano Amarelli, Francesco Musumeci, Antonio Loforte, Andrea Montalto, Sveva Di Franco and Jaime Hernandez-Montfort

R. Gregory Conway, Douglas Tran, Bartley P. Griffith and Zhongjun

Chapter 11 **Holder System for External Pumps Positioned Remote from the**

Chapter 12 **Utility of Modified Ultrafiltration in Congenital Heart Disease Patients Operated with Cardiopulmonary Bypass 169** Pedro José Curi-Curi, Juan Calderón-Colmenero, Samuel Ramírez-

Chapter 14 **Extracorporeal Membrane Oxygenation (ECMO) for Long-Term**

**Dysfunction (PGD) 89**

Takashi Murashita

Koen De Decker

Pierre Nakers

J. Wu

Chapter 15 **Ventricular Assist Devices 231**

**Section 2 Technology 133**

**VI** Contents

Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), has evolved to be a mainstream therapy for those requiring cardiac and/or pulmo‐ nary support for acute heart, lung, or heart and lung failure and who are failing convention medical therapies. With now thousands of cases being performed each year worldwide, it is rapidly evolving into a valuable tool in the management of critically ill patients. However, there is still much to be learned from a technology that is controversial, invasive, often cost‐ ly, and limited by a lack of convincing randomized trials. As experiences continue to grow, the hope is that outcomes will improve with better patient selection, better technologies, bet‐ ter guidelines and protocols for management, and a general understanding of the impor‐ tance of a team-based approach to managing extremely complex and sick patients. Critical to the success of ECMO therapy is the recognition that therapy must be initiated early before the onset of multiorgan dysfunction, neurologic complications, and the pathophysiologic consequences of irreversible shock. While veno-venous ECMO is often considered for pul‐ monary support and venoarterial for cardiac or cardiopulmonary support, the overlap in the management of acute heart and lung injuries can complicate decision making regarding the specific details of initiating therapy. Hopefully, the goal of this text—the second edition on the topic—is to lend further insights into some of the challenges that face providers, at all levels, who are interested in ECMO or use it routinely

This text is separated into several different areas—each focused on different aspects—of the management of patients who require extracorporeal support. While there are several chap‐ ters on general indications for ECMO—such as for respiratory failure, cardiogenic shock, and postcardiotomy shock—there are several chapters that focus on specific applications. These specific indications include, for example, the use of ECMO for high-risk catheterbased interventions, complications following heart transplant, and unusual applications in the neonate/newborn. Several chapters also focus on challenging topics regarding the use of ECMO and include advanced concepts such as flow optimization, pump circuit design, and the relationship to ventricular assist devices. An important topic that is also addressed is the role of simulation training as a critical component to the development and maintenance of competency of a high-quality ECMO program.

A theme common to many of the chapters is the importance of team communication with the focus on optimizing timely care for critically ill patients. Without doubt, the importance of early initiation of therapy prior to the sequelae of shock, hypoxemia, and hypotension resulting in end-organ damage and neurologic dysfunction cannot be overemphasized. Fur‐ thermore, once the decision is made to support a patient on ECMO, a primary goal is to allow the heart and/or lungs to rest and recover. Prevention of complications while on EC‐ MO is also paramount to good outcomes and is discussed in many of the chapters that focus on specific applications of ECMO.

Undoubtedly, ECMO is rapidly expanding throughout the world as it evolves into a valua‐ ble tool for the management of critically ill patients in cardiogenic shock or acute respiratory failure (or often a combination of both) regardless of the etiology. Hopefully, as the technol‐ ogy expands, and providers become more experienced with the specific indications, patient selection, pump circuit technology and interactions with human physiology, and the foun‐ dations for effect team functioning will be outcomes that will continue to be important. This text serves only as an update, and is by no means comprehensive, to the rapidly expanding literature on the topic of extracorporeal support.

#### **Michael S. Firstenberg, MD FACC FAIM**

Chief, Cardiothoracic and Vascular Surgery Director, Adult ECMO Program Associate Professor of Surgery and Integrative Medicine (Adjunct) Graduate Adjunct Faculty, College of Graduate Studies Northeast Ohio Medical Universities Rootstown, Ohio, USA

> Teaching Faculty The Rocky Vista University Parker, Colorado, USA

**Chapter 1**

**Provisional chapter**

**Introductory Chapter: ECMO - Growing Indications,**

**Introductory Chapter: ECMO - Growing Indications,** 

This volume represents the second in a series of texts focused on extra-corporeal membrane oxygenation (ECMO), also known as extra-corporeal life support (ECLS) [1]. Over the years, there has been a continuous evolution of this therapy from a salvage form employed only in extreme cases in which all other treatment options have failed to a technology which is now considered a critical component in the toolbox of therapies and technologies used for acute cardiopulmonary failure. While initial experiences reported few survivors, these poor outcomes clearly had multifactorial etiologies [2]. Difficulties with primitive pump and circuit designs and technologies, a poor understanding of which patients derive the greatest benefit from this therapy, little understanding of the long-term physiologic implications of patient-circuit biologic interactions, a lack of management guidelines, and a generally limited understanding of managing patients and therapy-related complications while on "longer" term cardiopulmonary bypass have all contributed to the complexities of successful implementation of ECMO into mainstream medical and surgical practices. Nevertheless, over the past three decades, there has been continued refinement in all aspects of ECMO therapies, with a growing understanding of the role of ECMO as a life-saving therapy and potential bridge to transplantation while awaiting organ availability. ECMO has evolved into a treatment option that allows for an acutely injured heart and or lungs to heal, either allowing for recovery or serving as a "bridge" to a more definitive long-term end-organ replacement option such as ventricular assist devices or cardiopulmonary transplantation [3]. Many of these complex topics are addressed in this contemporary volume. However, there remains, without a doubt, much more to learn and understand. The successes of the ECMO technology

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.81777

**Applications, and Understanding of a Complex**

**Applications, and Understanding of a Complex** 

**Supportive Therapy**

**Supportive Therapy**

Michael S. Firstenberg and Jennifer M. Hanna

Michael S. Firstenberg and Jennifer M. HannaAdditional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.81777

**1. Introduction**

The Medical Center of Aurora and Rose Hospitals Aurora, Colorado, USA

#### **Introductory Chapter: ECMO - Growing Indications, Applications, and Understanding of a Complex Supportive Therapy Introductory Chapter: ECMO - Growing Indications, Applications, and Understanding of a Complex Supportive Therapy**

DOI: 10.5772/intechopen.81777

Michael S. Firstenberg and Jennifer M. Hanna Michael S. Firstenberg and Jennifer M. HannaAdditional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.81777
