1. Neonatal ECMO
Chris Burke MD
March 6, 2014

2. Basics Types Requires systemic anticoagulation
Veno-arterial (VA): full cardiopulmonary support
Veno-venous (VV): pulmonary support only
Requires systemic anticoagulation
Perfusionist necessary to operate pump; differential flows allow for maximal support/weaning
Multiple complications exist: access site issues, bleeding, HIT, and thrombus formation

3. Types VA VV

5. History of ECMO

6. History of ECMO
John Gibbon credited with the first use of a prosthetic heart-lung machine for cardiac surgery in 1953
Early CPB was lethal after several hours
Kolobow, Bartlett, and others demonstrated that extracorporeal circulation of the blood could be carried out for days or weeks without toxicity or hemolysis, as long as direct blood-gas contact was avoided

7. History of ECMO
First successful ECMO case was in 1972 in San Francisco
Bartlett and his team performed first neonatal ECMO case in 1975 at UC-Irvine
Bartlett then moved to the University of Michigan, establishing the first neonatal ECMO program in 1980
The extracorporeal life support organization (ELSO) is formed in 1989

9. Bartlett et al 1985
Bartlett and his team had established safety of ECMO with case series in the late 1970s and early 1980s
In infants with birth weight greater than 2kg, survival on ECMO was 70%; in contrast to a 20% survival rate for infants treated with best medical management
The stage was set for the first randomized “phase 2” trial in neonates

10. Bartlett et al 1985
Trial utilized a unique, “randomized play-the-winner” design
Neonates greater than 2kg with a greater than 90% chance of demise were selected for the trial

11. Bartlett et al 1985
During the 18 months of enrollment, 12 patients were ultimately randomized
1 neonate in the control group; 11 in the ECMO cohort
Conventional treatment included maintaining PaO mmHg, hyperventilation +/- bicarb infusion to maintain PaCO2 < 35 mmHg and pH > 7.5

12. Bartlett et al 1985

13. Bartlett et al 1985
Control patient died of progressive respiratory failure 13 days after randomization

14. Bartlett et al 1985
Unique study design, but laid the ground-work for ECMO becoming routine in critically ill neonates
Long-term sequela were unknown
Four children went on to have developmental delay or mild neurologic problems
This trial and other early reports led to the establishment of several ECMO programs throughout the US

15. Low Birth Weight Infants

16. LBW Infants
Many guidelines suggest that ECMO may not be safe for neonates less than 2kg
Early reports in LBW infants revealed a nearly 80% mortality rate in this cohort
Concern over hemorrhagic complications, notably intracranial hemorrhage

18. LBW Infants
Authors sought to challenge the idea that ECMO is not safe in infants less than 2kg
Utilized the ELSO registry to obtain data on 14,305 neonates placed on ECMO between
13,642 HBW (greater than 2 kg)
663 LBW (less than 2 kg)

19. LBW Infants

20. LBW Infants

21. LBW Infants
Though survival in LBW infants is lower, it is still 53%, which is similar to the rate in older patients after cardiac failure and may be higher than the expected outcome if ECMO were not used in these cases
Infants weighing 1.6kg or more have an expected ECMO survival of 40%
Fatal bleeding more common in LBW infants more conservative anticoagulation strategy needed?
Selection bias may be present limitation of registry study

22. Long-term Outcomes

24. Jaillard et al 2000
Single center retrospective review sought to evaluate long-term outcomes in neonatal ECMO
All cases of ECMO reviewed from Oct 1991-Sep 1997
Infants were followed with serial neurodevelopmental, respiratory, and digestive evaluations

25. Jaillard et al 2000 57 infants enrolled in the study
CDH (n=23), sepsis (n=14), MAS (n=12), others (n=8)
Mean time of onset was 70 h
Mean duration of ECMO was 134 h

26. Jaillard et al 2000 Survival at two-years was 40/57 (70%)
CDH 52%, NS 79%, MAS 100%, others 62%
Ten neonates died on ECMO
Five technical complications were noted on ECMO
Pump malfunction (2), air in circuit (1), hemorrhage (1), heat exchanger malfunction (1)

27. Jaillard et al 2000
Two infants with clinical vision anomalies; one infant with severe hearing loss requiring prosthesis
45% of infants were oxygen-dependent at 28 days (83% CDH)
Four infants required tracheostomy (all CDH)
Two infants were O2 dependent at two-years (both CDH)
Growth retardation in 12 infants; GERD noted in 11
Four required G-tube (all CDH)
95% of carotid reconstructions were patent at two-years

28. Jaillard et al 2000
Survival was high in all groups with limited morbidity; however, CDH infants fared worse than their counterparts
All carotid arteries were reconstructed with good anatomic outcome
Neonates with CDH remain a significant challenge

29. Congenital Diaphragmatic Hernia

30. CDH Between 20-40% of infants with CDH require ECMO rescue therapy
VA ECMO has traditionally been the predominant form in CDH
VV ECMO has several advantages
Spares ligation of the carotid artery
Minimizes embolic risk to the brain
Perfusion of the pulmonary vasculature
Maintenance of pulsatile flow

32. VV vs. VA
Disease-severity risk-adjusted analysis of VV and VA ECMO outcomes in CDH
Utilized the ELSO database ( )
Primary outcome was in-hospital mortality; secondary outcomes included complication rates

33. VV vs. VA

34. VV vs. VA

35. VV vs. VA
No differences in the risk-adjusted odds of mortality between infants with CDH undergoing VV vs. VA ECMO [46% vs 50%, p=.03]
Echocardiographic data was excluded from this analysis
18% conversion rate from VV to VA ECMO; this carried a 56% mortality rate
VV ECMO may be a feasible option in infants with CDH