Balloon Counterpulsation Together with Bio-Medicus Pump Closed Circuit Membrane Oxygenation for Left Ventricular Assist: A Case Report

___________ _ A 23-year old male was admitted at 1 ,093 days post cardiac transplantation in cardiac failure. Despite inotropic support and later intra-aortic balloon pumping there was a slow continued fall in cardiac output, renal function and a worsening metabolic state. The patient was then placed on extracorporeal membrane oxygenation (ECMO), consisting of a Bio-Medicus pump and Kolobow membrane o'Xygenator in a closed circuit configuration (without reservoir). Vascular access was by femoral artery and vein using a non-obstructive technique. Anticoagulation management consisted of a heparin infusion of 2,000 Iu/hour into a peripheral line to an ACT of 170 seconds and a prostacyclin infusion of 3ng/Kg/min. into the venous line. Induction of ECMO was followed by a rapid hemodynamic and metabolic improvement allowing the patient to sit up, talk and eat normally. One hundred and one hours later a new donor organ was located and transplanted. This system has much to recommend it. The equipment forms a compact module. The device functions safely with minimal perfusionist supervision. The system produces excellent hemodynamic function and Presented at AmSect's 22nd International Conference, May 21-23, 1984, Las Vegas, NV. Direct communications to: David Gifford, Department of Clinical Perfusion, Papworth Hospital, Papworth Everard, Cambridge, England Volume 18, Number 1, Spring 1986 offers effective short and medium term support for a range of cardiac and pulmonary disorders. Introduction ___________ _ Extracorporeal membrane oxygenation (ECMO) has been used for the treatment of acute respiratory distress syndrome (ARDS), massive pulmonary thromboembolism and ventricular failure. The extracorporeal approach assumes that dysfunction is a reversible short lived state in ARDS, and that in chronic ventricular failure ECMO support can be an effective interim measure until cardiac transplantation can be carried out. This case report examines primarily one of severe cardiac failure in the transplanted heart and the support system used. It also looks briefly at the whole Papworth support perfusion experience. Pre-1983 Experience ________ _ By 1979 there had been many cases reported of the use of ECMO in ARDS, cardiac failure leading to transplantation, as well as its effective use as a ventricular assist device for post-cardiac surgery patients in cardiogenic shock.l.2.3.4.5.6. In 1979 a 15-year old male was admitted to Papworth Hospital with ARDS, right ventricular and renal failure, following a partial drowning accident and 17 days of ineffective intermittent positive pressure ventilation (IPPV). The patient was placed on veno-veno support The Journal of Extra-Corporeal Technology 29 '[' ', 11 ~e~arin ij .. ..,, ! , • Reservoir! lj 1, .·· ~ g;,l 'I . , i .g 0' ' 'II ,,· ~ r' · ~~ l''li /$ r· H~~t Exch. 11 I' I 8 B Figure 1: Papworth Support Perfusion Circuit 1979. perfusion using a basic membrane lung circuit (2.5 m2 Kolobow with 500 ml reservoir). A hollow fiber dialyser was added to the circuit via a shunt line (Figure 1). There followed an improvement in the patient's biochemical, hemodynamic, and central nervous state. The system was run at a flow of 1.0-1.6 Llmin. Dialysis produced a fall in serum potassium from 7. 0 to 5. 5 mmol/ 1. A modest hypothermia level of 35 oc was maintained. However, after 38.5 hours of perfusion, it became clear that the patient's cardiopulmonary system had been irreversibly damaged in the first 17 days of care and ECMO support was therefore discontinued. The second case was a soldier who had inhaled toxic gas during a military exercise. He was admitted to Papworth Hospital ICU with ARDS, where after a short period of ineffective IPPV he was placed on ECMO support perfusion. After 18 hours his lung function had recovered sufficiently to allow conventional ventilatory management. Adequate arterial p02 was produced on 60 percent inspired oxygen. This patient was eventually discharged from hospital. The support system used on these two patients, although it functioned adequately, required round-theclock perfusionist control, producing many logistical problems in a busy cardiothoracic unit. It proved to be a heavy load on the perfusion resources at Papworth and consequently could not be adopted for routine use in the treatment of ARDS or cardiac failure. Case Report ____________ _ A 25-year old 70 kilogram male was admitted 1,093 days post-cardiac transplantation in severe cardiac failure. His postoperative course during the first six to nine months following his transplant on June 4, 1980, had 30 The Journal of Extra-Corporeal Technology been characterized by recurrent rejection episodes which were difficult to control. He had bilateral pneumothoraces and an aspergillus infection of the right lung which were successfully treated. One month following organ grafting he had a series of grand-mal convulsions which were also subsequently controlled . He experienced episodes of epilepsy for the next three years. At eight months post-transplant he was fitted with a programmable pacemaker for sinus node dysfunction. Thereafter he recovered satisfactorily and had a good quality of life, returning to full employment. Selective coronary angiograms at two years showed the presence of moderately extensive coronary arterial disease. There were 70 percent marginal, 50 percent left anterior descending and 20 percent right coronary artery stenoses. However he remained well until the middle of May 1983 when he was admitted to Pap worth with a short history of fluid retention. This responded to diuretic therapy. As the possibility of left ventricular dysfunction form coronary artery atherosclerosis was considered, a nuclear left ventricular gated study* was carried out which showed reduced left ventricular function. Cardiac biopsy showed no evidence of acute rejection so he was discharged to be re-admitted two weeks later for his three-year follow up study. Eleven days later, on May 31 , 1983, he was readmitted to Papworth as an emergency with a four-day history of vomiting and being generally unwell. On examination he had generalized edema, a tachycardia, and a blood pressure of only 80/50 mm.Hg., with a central venous pressure (CVP) of 12 mm. Hg. He was confused, hypoxemic and oliguric with a severe metabolic acidosis. Very soon after admission inotropic support was started, but despite increasing doses there was no improvement. Intra-aortic balloon pump (IABP) counterpuslation was started on the next day, after a percutaneous balloon had been inserted through the right femoral artery. This also failed to improve his circulation satisfactorily. He remained with a low cardiac *Note: The Nuclear Gated Study: Radionuclide Ventriculography. A radionuclide (Technetium 99 m bound to human serum albumins) is injected into the patient"s blood stream. A collimated N" I scintillation gamma camera takes counts, for up to 5 minutes, in 20 milli second counts up to 600 times, triggered by the R wave of the EKG. By use of a computer, these 'gated' counts are built up to form a picture. Commonly 22 pictures are built up to observe different stages of the cardiac cycle. Regional wall motions can be accurately examined, as well as ejection and regional ejection fractions and blood transit times. This technique can provide data safely which is very difficult or impossible to obtain by other diagnostic means, such as angiography. II Volume 18, Number I, Spring 1986 output, a blood pressure of 70/45 mmHg., a CVP of 28 mmHg., and a persistent acidosis with a base deficit of -15 mEq/L. His Pa02 was only 80 mmHg. on an Fi02 of .50. Swan-Ganz thermal dilution determinations showed a cardiac output of under 2.0 liters/minute. At this stage he was anuric and semicomatose. It was therefore decided that supportive perfusion should be instituted while urgent efforts were made to locate a new heart. Methods and Materials _______ _ A closed ECMO (without reservoir) system was set up, comprising a 2.5 m2 Kolobow SciMed• membrane lung with integral heat exchanger, a Bio-Medicush model 600 centrifugal blood pump with its control electromagnetic flow meter, and a 3/s inch polyvinyl chloride tubing sash (Figure 2). , Infusion 'Line Arterial Return Figure 2: Papworth Support Perfusion Circuit. The circuit was primed with 400 ml of 5 percent albumin (to coat internal surfaces), followed by 500 ml Hartmann's solution and 3,000 Iu of heparin. A CO/ vacuum method was used for priming. The ECMO system together with a small water circulator (used to supply thermal control via the integral heat exchanger), was mounted on a small trolley so that the pump and oxygenator were close to ground level to aid gravity drainage. The patient was moved to the operating room. A transverse cut down incision was made in the left groin down to the femoral artery and vein at the junction of the great saphena-femoral vein (Figure 3). The patient was given a bolus of 12,000 Iu heparin. The arterial cannulation consisted of a 14 French Bard cannula passed through a purse string in a manner so as not to a Bio-Medicus, Minnetonka, MN 55343 b SciMed Life Systems Inc., Minneapolis, MN 55441 Volume 18, Number 1, Spring 1986 obstruct distal perfusion. A 24 French USCI wire reinforced cannula was then introduced via the femoralsaphenous junction for venous drainage. Both cannulae were then tunnelled out some 5 centimeters below the primary incision in order to reduce the risk of infection, the cannulae were then secured to the skin. Both cannulae were then connected to the support perfusion circuit. Hemostasis was achieved, the skin closed and the system was then run at a blood flow of2.0 liters/minute