1. The document describes a case of a 28-year-old female with cyanotic congenital heart disease who underwent an arterial switch operation with integrated ECMO support. 2. ECMO is a form of extracorporeal life support used for both cardiac and respiratory failure in adults. It involves pumping blood out of the body to an artificial lung for gas exchange before returning it to circulation. 3. The key components of an ECMO circuit include a blood pump, membrane oxygenator, tubing, heat exchanger, and monitoring equipment. Proper anticoagulation and flow rates are important for safety and effectiveness.

1. ADULT ECMO

2. CASE:
• 28 YR OLD FEMALE WITH
• PREOPERATIVE PROFILE: H/O CYANOSIS SINCE BIRTH WITH RECURRENT LRTI,CLUBBING+,SPO2 ON
ROOM AIR-58%,BSA=1.4 SQ MTR
• DIAGNOSIS OF CCHD,INC Qp, d-TGA,LARGE OS-ASD(BIDIRECTIONAL SHUNTING),NO VSD,SEV PAH,
BVFNL,NO CLOT/VEG/PE,NSR, 2D ECHO-TRIVIAL TR/PR, RVSP=RAP+80, Ao/Laes=28/30,
Lves/Lved=25/40, Lves/PW(LV)ed=8/8,EF=65%, NO AS/COA/PDA, B/L CONFLUENT PA,D SHAPED LV, LV
MASS=57 GM,LV MASS INDEX=42 GM/SQ CM,
• LV ANGIO:LVSP= 57 mmHg LESS THAN 2/3 OF RVSP=101 mmHg
• CECT: CORONARIES ARISING FROM SEPARATE FACING PA’s,MULTIPLE APC’s, LEFT AORTIC ARCH WITH
BOVINE BRANCHING PATTERN, AP COMPRESSION OF LEFT PROXIMAL BRONCHUS BY DILATED LPA.
• ASO WITH INTEGRATED ECMO, AoClX=70 MINS.

7. DAY 0

9. DAY1

11. DAY2

13. DAY3

15. DAY 4

16. Artificial cardiac or pulmonary support acronym
• ECMO - Extracorporeal membrane oxygenation
• ECLS - Extracorporeal life support
• ECCOR/ECCO2R- Extracorporeal carbon dioxide removal
• PECCO2 - Partial extracorporeal carbon dioxide removal
• AVCOR - Arteriovenous carbon dioxide removal
• ECLA - Extracorporeal lung assist
• IVOX - Intravascular oxygenator

17. HISTORY OF ECMO
• ECLS / development of the heart-lung machine BY Dr. John H. Gibbon Jr.
• ECMO was introduced for the treatment of severe acute respiratory
distress syndrome (ARDS) in the 1970s.
• Dr. Theodore Kolobow - flow patterns in the membrane lung, method of
layering silicone and the design of vascular access catheters
• There was revival of interest only after Dr. Robert H. Bartlett in 1976
reported the first neonatal ECMO survivor, baby Esperanza.
• an ECMO registry was established in 1980 at the University of Michigan.
• Dr. John Toomasain in 1984 created the Neonatal ECMO Registry.
• In 1989, charter for Extracoporeal Life Support Organization (ELSO) was
formed with the purpose of stimulating multi-institutional research in the
field of acute lung injury and its therapy.

18. Uses of extracorporeal membrane oxygenation
In adults
• Cardiac failure
• Respiratory failure

19. Use and Strategy
Cardiopulmonary Extracorporeal Life Support (ECLS) is indicated in
severe, refractory circulatory failure with reversibility and/or timely,
reasonable therapeutic options.
• 1. There are four primary strategies for ECLS use, depending on the
• therapeutic objective for the patient.
• a) Bridge to recovery (reversible disease),
• b) Bridge to bridge (goal to transition to VAD or oxygenator),
• c) Bridge to organ transplantation
• d) Bridge to decision (providing time for recovery, diagnosis, or
• determination of candidacy for alternative support /transplantation).

20. Use of extracorporeal life support for cardiac failure should be
considered for patients with evidence of inadequate end organ perfusion
and oxygen delivery resulting from inadequate systemic cardiac output.
a) Hypotension despite maximum doses of two inotropic or vasopressor
medications.
b) Low cardiac output with evidence of end organ malperfusion despite
medical support
c) Low cardiac output with mixed venous, or superior caval central venous
(for single ventricle patients) oxygen saturation <50% despite maximal
medical support.
d) Low cardiac output with persistent lactate >4.0 and persistent upward
trend despite optimization of volume status and maximal medical
management.

21. ACUTE CARDIAC FAILURE: INDICATIONS
I. Patient condition
A. Indication for ECMO in adult cardiac failure is cardiogenic shock:
1. Inadequate tissue perfusion manifested as hypotension and low cardiac
output despite adequate intravascular volume.
2. Shock persists despite volume administration, inotropes and
vasoconstrictors, and intraaortic balloon counterpulsation if appropriate.
3. Typical causes: Acute myocardial infarction, Myocarditis, Peripartum
Cardiomyopathy, Decompensated chronic heart failure, Post cardiotomy
shock.
4. Septic Shock is an indication in some centers

22. ….INDICATIONS (CONTD….)
• Options for temporary circulatory support
Surgical temporary VAD: Abiomed, Levitronix
Percutaneous VAD:TandemHeart, Impella
• ECMO: Advantages: Biventricular support, bedside immediate application,
oxygenation,Biventricular failure, Refractory malignant arrythmias, Heart
failure with severe pulmonary failure
• ECMO is a bridge to…
 Recovery: Acute MI after revascularization, Myocarditis, Postcardiotomy
Transplant: Unrevascularizable acute MI, Chronic heart failure
Implantable circulatory support: Ventricular assist devices….
Surgical temporary VAD: Abiomed, Levitronix
Percutaneous VAD: TandemHeart, Impella

23. Contraindications to ECMO
1. Absolute:
• Unrecoverable heart and not a candidate for transplant or VAD,
• Advanced age,
• Chronic organ dysfunction (emphysema, cirrhosis, renal failure),
• Compliance (financial, cognitive, psychiatric, or social limitations),
• Prolonged CPR without adequate tissue perfusion.
2. Relative:
• Contraindication for anticoagulation,
• Advanced age,
• Obesity.

24. Vascular Access
• A. Postcardiotomy
• Intrathoracic cannulae: ensure site hemostasis, Patch chest open for
frequent exploration.
• B. Non-postcardiotomy
• Percutaneous femoral artery and vein, Typically most rapid access, 15-21 Fr
arterial, 21-28 Fr venous (advance to right atrium if possible).
• Percutaneous jugular vein, 21-28 Fr to right atrium,
• Common carotid via surgical exploration……10-15% watershed cerebral
infarction with carotid ligation, 8-10 mm end to side polyester graft
• Femoral arterial cannulation associated with ipsilateral leg ischemia,
• Percutaneous distal cannulation of superficial femoral artery (may require
ultrasound or fluoroscopic guidance),
• Surgical exploration of superficial femoral artery,
• Surgical exploration of posterior tibial artery 8Fr retrograde cannula.

25. Extracorporeal membrane oxygenation
indication indices for >80% predicted mortality
Likely to die (predicted 80% mortality)
• Oxygenation Index (OI) > 40 or > 35 for 4 hours {{OI = (MAP × FiO2 ×
100) / PaO2}}
• Ventilation Index (VI) > 90 for 4 hours {{VI = RR × PIP – PEEP/1000}}
• Alveolar–arterial oxygen difference [(A − a)DO2] >600 − 624 mmHg (at
sea level) despite 4–12 hours of medical management
(A − a)DO2 = [atmospheric pressure – 47] – (PaCO2 + PaO2)/FiO2
• PaO2 < 50 mmHg for 2–12 hours (FiO2 of 100%)
• Acute deterioration PaO2: < 30–40 mmHg (FiO2 of 100%)
• pH < 7.25 for 2 hours
• Intractable hypotension

26. ECMO CIRCUIT

27. The circuit is planned to be capable of total support for the patient
involved. Access is always venoarterial. The circuit components are
selected to support blood flow 3 L/m2/min.
• a) Neonates 100 cc/kg/min
• b) Infants and children 80 cc/kg/min
• c) Adults 60 cc/kg/min
2. The best measure of adequate systemic perfusion is a circuit mixed
venous saturation greater than 70%

28. CIRCUIT COMPONENTS
The basic circuit includes a
• blood pump,
• a membrane lung,
• conduit tubing.
• heat exchanger,
• monitors,
• alarms.

29. BLOOD PUMP
modified roller with inlet pressure control/ centrifugal / axial rotary pump with
inlet pressure control/ peristaltic pump).
• a) Inlet (suction) pressure. With the inlet line occluded, the suction pressure should not
exceed -300 mmHg. The inlet pressure can be very low (-300 mmHg) when the venous
drainage is occluded (chattering) which causes hemolysis. Inlet pressure in excess of -300
mmHg can be avoided by inherent pump design or through a servocontrolled pressure
sensor on the pump inlet side.
• b) Outlet pressure. With the outlet line occluded, the outlet pressure should not exceed
400 mm/Hg (inherent in the pump design or by a servocontrolled system).
• c) Power failure. The pump should have a battery capable of at least one-hour operation,
and a system to hand crank the pump in the event of power failure. The pump and circuit
should have a mechanism to alarm for or prevent reverse flow (arterial to venous in the
VA mode) if the power fails.
• d) Hemolysis. The plasma hemoglobin should be less than 10 mg/dl under most
conditions.

30. Membrane lung (Oxygenator)
• A)silicone rubber,/a microporous hollow-fibre (e.g. polypropylene), /
a solid hollow-fibre membrane (e.g. polymethylpentene
• b) Membrane surface area and mixing in the blood path determine
the maximum oxygenation, described as “rated flow” or “maximal
oxygen delivery”.
• c) Rated flow is the blood flow rate at which venous blood (saturation
75%, Hb 12 g/dl) will be fully saturated (95%) at the outlet of the
membrane lung. Maximal O2 delivery is the amount of oxygen
delivered per minute when running at rated flow.
• d) This is calculated as outlet minus inlet O2 content (typically 4-5
cc/dL, same as the normal lung) times blood flow.

31. Sweep gas
a) The sweep gas can be 100% oxygen, carbogen (5% CO2, 95% O2)
or a mixture of oxygen and compressed room delivered via an oxygen-
air blender.
b) The initial sweep gas flow rate is usually equal to the blood flow rate
(1:1).
c) Increasing the sweep flow will increase CO2 clearance but will not
affect oxygenation.
d) Water vapor can condense in the membrane lung resulting in poor
CO2 clearance, and may be cleared by intermittently increasing sweep
gas flow to a higher flow.

32. Priming the circuit
a) Isotonic electrolyte solution resembling normal extracellular fluid
including 4-5 mEq/L potassium. The prime is circulated through a
reservoir bag until all bubbles are removed.
b) Before attaching the circuit to the patient, the water bath is turned
on to warm the fluid.

33. HEAT EXCHANGER
• Heat exchangers require an external water bath, which circulates
heated (or cooled) water through the heat exchange device.
a) In general, the temperature of the water bath is maintained <40º
Celsius, and usually at 37º.
b) Contact between the circulating water and the circulating blood is very
rare, but should be considered if small amounts of blood or protein are
present in the circulating water, or if unexplained hemolysis occurs.
c) The water in the water bath is not sterile and may become
contaminated. The water bath should be cleaned and treated with a
liquid antiseptic from time to time.

34. MONITORS
a) Monitoring of blood flow is by direct measurement using an ultrasonic detector, or calculated
based on pump capacity and revolutions per minute for a roller pump using standardized tubing.
b) Pre- and post- membrane lung blood pressure measurements can include maximum pressure servo
regulation control to avoid over pressuring.
c) Pre- pump venous drainage line pressure (to avoid excessive negative suction pressure by the pump)
can be used as a servo regulation system to prevent excessive suction.
d) Pre- and post- membrane lung oxyhemoglobin saturation measurements: The venous oxyhemoglobin
saturation is a valuable parameter for managing and monitoring both circuit and patient factors related
to oxygen delivery and consumption. The post membrane lung saturation monitor will determine if the
membrane lung is working at rated flow, and if function is deteriorating. Blood gases are measured from
pre-oxygenator and post-oxygenator sites either by continuous on line monitoring or batch sampling. The
primary purpose of measuring blood gases (as opposed to online saturation) is to determine the inlet
and outlet PCO2 to evaluate membrane lung function, and blood pH to determine metabolic status.
e) Circuit access for monitors, blood sampling, and infusions. Luer connectors and stopcocks provide
access to the blood in the circuit.

35. ALARMS
a) Pre- and post- membrane lung pressure alarms. These
measurements will determine the transmembrane lung pressure
gradient. Clotting in the oxygenator is represented by increasing
membrane lung pressure gradient.
b) Many centers use a bubble detector on the blood return line.
Pressure and bubble detector alarms can be used to clamp lines and
turn the pump on or off to automate these safety factors.

36. TUBING AND BRIDGE
• Internal diameter in inches is:
(1) 3/16: 1.2 L/min;
(2) ¼: 2.5 L/min;
(3) 3/8: 5 L/min;
(4) ½: 10 L/min
c) A “bridge” between the arterial and venous lines close to the patient
is a useful circuit component, particularly for periods off bypass during
VA access, during weaning, or during an emergency. However, when
clamped the bridge is a stagnant area that can contribute to
thrombosis and possibly infection. In general, if a bridge is used, it
should be maintained closed during most of the ECLS run, with a
system for purging the bridge of stagnant blood when it is not in use.

37. Anticoagulation on ECMO
• Heparin is required after arterial and venous cannulation, 100 IU/kg
bolus followed by infusion of 125 IU/kg/hour to maintain an ACT at
180–200 s.

38. Types of ECMO circuits
• Veno-arterial (VA)
• Venovenous (VV)
• Veno-arterial-venous (VAV)

40. Factors increasing oxygenation in venous–
arterial extracorporeal membrane oxygenation
• Increased hemoglobin
• Increased flow
• Increased mixed venous O2
• Decreased shunt flow

41. DOUBLE LUMEN CANNULA

42. Targets on veno-venous extracorporeal
membrane oxygenation
• SaO2 - 85–95%
• PaO2 - 45–55 mmHg
• Hematocrit >5% of normal baseline

43. Factors increasing oxygenation on venovenous
extracorporeal membrane oxygenation
• Increasing ECMO flow (no change in systemic flow)
• Decreasing % of recirculated flow
• Increased hemoglobin
• Increased mixed venous oxygen (decreased oxygen consumption)
• Increased cardiac output

44. Advantages of veno-venous extracorporeal
membrane oxygenation
• Avoids ligation of carotid artery
• Thromboembolism to systemic artery avoided
• Decreased risk of neuronal injury
• Decreased potential for ischemic lung injury
• Preserves normal physiological pulsations

45. Variants of veno-venous extracorporeal
membrane oxygenation
• Single site cannulation
• Two site cannulation
• Extracorporeal CO2 removal (ECO2R)
• Tidal flow VV ECMO

46. Indications for conversion from veno-venous
to veno-arterial-venous or veno-arterial
extracorporeal membrane oxygenation
• Inability to maintain systemic perfusion
• Maximal ionotropic support with inadequate systemic pressures
• Poor cardiac function on echocardiogram
• High serum lactate > 8 mmol/l and persistent metabolic acidosis
• Ongoing base excess ≥ -6
• Deterioration of cardiac function

47. O2 exchange (blood flow variables)
Dependent on:
• O2 concentration (driving gradient)
• Blood flow rate
• Blood path thickness
• Membrane surface area
• Membrane diffusion characteristics
• Independent of sweep gas flow