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Physical therapy in successful venoarterial extracorporeal membrane oxygenation bridge to orthotopic heart transplantation

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Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a temporary mechanical circulatory support system that may be used as a lifesaving therapy for patients in acute heart failure and as a bridge to definitive management. Physical therapy in these patients remains challenging, with limited protocols to guide practitioners. Methods: We describe a case of a 37-year-old gentleman who presented with familial cardiomyopathy and cardiogenic shock. Results: Our patient underwent urgent peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) followed by successful heart transplantation. While on ECMO support he was enrolled in a physical therapy program that included the VitalGo Tilt Bed to improve lower body weight bearing while avoiding hip flexion and damage to the peripheral ECMO cannulae. The patient was discharged home expeditiously after heart transplant due to aggressive physical rehabilitation while on full VA-ECMO support. Conclusions: Early intensive physical rehabilitation is feasible and safe and may result in improved outcomes and expeditious discharge in VA ECMO patients. Protocol driven multidisciplinary physical therapy with a patient on femorally cannulated VA-ECMO retains the advantages of lower extremity peripheral cannulation while eliminating the risks of immobility. The new UNOS allocation system may result in a successful bridge to transplantation in patients on VA-ECMO due to the increased prioritization of this population to receive donor organs.
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J Card Surg. 2019;34:13901392.wileyonlinelibrary.com/journal/jocs1390
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© 2019 Wiley Periodicals, Inc.
DOI: 10.1111/jocs.14220
CASE REPORT
Physical therapy in successful venoarterial extracorporeal
membrane oxygenation bridge to orthotopic heart
transplantation
Daniel Rinewalt MD
1
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Yasuhiro Shudo MD, PhD
1
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Masataka Kawana MD, PhD
2
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Y. Joseph Woo MD
1
1
Department of Cardiothoracic Surgery,
Stanford University, Palo Alto, California
2
Cardiovascular Institute, Stanford University,
Palo Alto, California
Correspondence
Y. Joseph Woo, MD, Falk Cardiovascular
Research Center, Department of
Cardiothoracic Surgery, Stanford University
School of Medicine, Stanford, CA 94305.
Email: joswoo@stanford.edu
Abstract
Background: Venoarterial extracorporeal membrane oxygenation (VAECMO) is a
temporary mechanical circulatory support system that may be used as a lifesaving
therapy for patients in acute heart failure and as a bridge to definitive management.
Physical therapy in these patients remains challenging, with limited protocols to guide
practitioners.
Methods: We describe a case of a 37yearold gentleman who presented with familial
cardiomyopathy and cardiogenic shock.
Results: Our patient underwent urgent peripheral venoarterial extracorporeal membrane
oxygenation (VAECMO) followed by successful heart transplantation. While on ECMO
support he was enrolled in a physical therapy program that included the VitalGo Tilt Bed
to improve lower body weight bearing while avoiding hip flexion and damage to the
peripheral ECMO cannulae. The patient was discharged home expeditiously after heart
transplant due to aggressive physical rehabilitation while on full VAECMO support.
Conclusions: Early intensive physical rehabilitation is feasible and safe and may result
in improved outcomes and expeditious discharge in VA ECMO patients. Protocol
driven multidisciplinary physical therapy with a patient on femorally cannulated VA
ECMO retains the advantages of lower extremity peripheral cannulation while
eliminating the risks of immobility. The new UNOS allocation system may result in a
successful bridge to transplantation in patients on VAECMO due to the increased
prioritization of this population to receive donor organs.
KEYWORDS
extracorporeal membrane oxygenation, organ allocation, orthotopic heart transplantation
CENTRAL MESSAGE
Early and aggressive physical therapy can and should be utilized in
VAECMO patients.
PERSPECTIVE STATEMENT
VAECMO is often be used as a bridge to heart transplantation
as the new UNOS allocation system these patients the highest priority,
meaning fewer patients will likely succumb to complications while on the
wait list. A multidisciplinary approach for optimizing strength and
endurance using protocoldriven intensive physical therapy with a patient
on femorally cannulated VAECMO is ideal.
Abbreviations: IABP, intraaortic balloon pump; UNOS, United Network for Organ Sharing;
VAECMO, venoarterial extracorporeal membrane oxygenation.
Article
Background and purpose: Extracorporeal membrane oxygenation (ECMO) continues to play an essential role in organ support in cardiogenic shock or acute respiratory distress syndrome and bridging to transplantation. The main purpose of the present survey was to define which clinical and organizational practices are adopted for the administration of physiotherapy in adult patients undergoing ECMO support worldwide. Methods: This international survey was conceived in November 2021. The survey launch was announced at the 10th EuroELSO (European ELSO chapter) Congress, London, May 2022. Results: The survey returned 32 questionnaires from 29 centers across 14 countries. 17 centers (53.1%) had more than 30 intensive care unit beds available and most (46.8%) were able to care for five to 10 patients on extracorporeal life support simultaneously. The predominant physiotherapist-to-patient ratio was 1:>5 (37.5%); physiotherapy was available 5/7 days and 7/7 days by 31.2% and 25% respectively. Respiratory physiotherapy was not defined by a specific protocol in most centers (46.8%) while 31.2% declared that the treatment commences less than 12 h after sedation is stopped/reduced. Mostly, early physiotherapy in non-cooperative ventilated patients was provided within the first 48 h (68.6%) and consisted of as passive range of motion, in-bed positioning, and splinting. Postural passages and sitting were provided to patients and walking was included in those advanced motor activities which are part of the treatment. Conclusion: Physiotherapy in patients on ECLS is feasible, however substantial variability exists between centers with a trend of delivering not protocolized and understaffed rehabilitation practices.
Article
Background and purpose:Extracorporeal membrane oxygenation (ECMO) continues to play an essential role in organsupport in cardiogenic shock or acute respiratory distress syndrome and bridging to transplantation. The main purpose ofthe present survey was to define which clinical and organizational practices are adopted for the administration ofphysiotherapy in adult patients undergoing ECMO support worldwide.Methods:This international survey was conceived in November 2021. The survey launch was announced at the 10thEuroELSO (European ELSO chapter) Congress, London, May 2022.Results:The survey returned 32 questionnaires from 29 centers across 14 countries. 17 centers (53.1%) had more than 30intensive care unit beds available and most (46.8%) were able to care forfive to 10 patients on extracorporeal life supportsimultaneously. The predominant physiotherapist-to-patient ratio was 1:>5 (37.5%); physiotherapy was available 5/7 daysand 7/7 days by 31.2% and 25% respectively. Respiratory physiotherapy was not defined by a specific protocol in mostcenters (46.8%) while 31.2% declared that the treatment commences less than 12 h after sedation is stopped/reduced.Mostly, early physiotherapy in non-cooperative ventilated patients was provided within thefirst 48 h (68.6%) and consistedof as passive range of motion, in-bed positioning, and splinting. Postural passages and sitting were provided to patients andwalking was included in those advanced motor activities which are part of the treatment.Conclusion:Physiotherapy in patients on ECLS is feasible, however substantial variability exists between centers with a trendof delivering not protocolized and understaffed rehabilitation practices.
Article
Full-text available
Background: In Spain, listing for high-urgent heart transplantation is allowed for critically ill candidates not weanable from temporary mechanical circulatory support (T-MCS). We sought to analyse the clinical outcomes of this strategy. Methods and results: We conducted a case-by-case, retrospective review of clinical records of 291 adult patients listed for high-urgent heart transplantation under temporary devices from 2010 to 2015 in 16 Spanish institutions. Survival after listing and adverse clinical events were studied. At the time of listing, 169 (58%) patients were supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO), 70 (24%) on temporary left ventricular assist devices (T-LVAD) and 52 (18%) on temporary biventricular assist devices (T-BiVAD). Seven patients transitioned from VA-ECMO to temporary ventricular assist devices while on the waiting list. Mean time on T-MCS was 13.1 ± 12.6 days. Mean time from listing to transplantation was 7.6 ± 8.5 days. Overall, 230 (79%) patients were transplanted and 54 (18.6%) died during MCS. In-hospital postoperative mortality after transplantation was 33.3%, 11.9% and 26.2% for patients bridged on VA-ECMO, T-LVAD and T-BiVAD, respectively (P = 0.008). Overall survival from listing to hospital discharge was 54.4%, 78.6% and 55.8%, respectively (P = 0.002). T-LVAD support was independently associated with a lower risk of death over the first year after listing (hazard ratio 0.52, 95% confidence interval 0.30-0.92). Patients treated with VA-ECMO showed the highest incidence rate of adverse clinical events associated with T-MCS. Conclusion: Temporary devices may be used to bridge critically ill candidates directly to heart transplantation in a setting of short waiting list times, as is the case of Spain. In our series, bridging with T-LVAD was associated with more favourable outcomes than bridging with T-BiVAD or VA-ECMO.
Article
Objectives: To examine the feasibility and safety of mobilizing patients while on extracorporeal membranous oxygenation support. Design: Retrospective cohort study. Setting: Medical and Surgical ICUs in a large tertiary care hospital in the United States. Patients: Adults supported on extracorporeal membranous oxygenation from January 2014 to December 2015. Measurements and main results: We reviewed the medical records from physical therapy, perfusion, and intensivists to obtain the number and type of physical therapy interventions and discharge status; extracorporeal membranous oxygenation type and description of support, cannulation sites; and risk management details of adverse effects, if any. Of 254 patients supported on extracorporeal membranous oxygenation, 167 patients (66.7%) received a total of 607 physical therapy sessions while on extracorporeal membranous oxygenation support. In this cohort, 134 patients (80.2%) had at least one femoral cannula during physical therapy intervention. Sixty-six of the 167 patients (39.5%) were supported on extracorporeal membranous oxygenation with bifemoral cannulas, and 44 (26.3%) were on veno-arterial extracorporeal membranous oxygenation. A dual lumen catheter was only used in five cases. Twenty-five patients (15%) (13 bifemoral cases) participated in standing or ambulation activities. Seventy-five patients (68.8%) who were successfully weaned from extracorporeal membranous oxygenation were discharged to a rehabilitation facility; 26 patients (23.8%) went home. Three minor events (< 0.5%) involving two episodes of arrhythmias and a hypotension event interrupted the therapy sessions, but mobility activities and exercises resumed that day. No major events were reported. Conclusions: With a highly trained multidisciplinary team and a focus on restoring function, it is feasible and safe to deliver early rehabilitation including standing and ambulation to patients on extracorporeal membranous oxygenation support even those with femoral cannulation sites with veno-arterial extracorporeal membranous oxygenation and veno-venous extracorporeal membranous oxygenation.
Article
Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a short-term circulatory support in patients with refractory cardiogenic shock providing a bridge to long-term mechanical circulatory support or transplantation. In France, a higher priority status is granted to transplant candidates on VA-ECMO than to those on long-term mechanical circulatory support. This study aimed to evaluate the impact of transplantation as primary therapy on survival in patients on VA-ECMO at listing. Methods: This was a retrospective analysis of data from the French national registry CRISTAL including all patients (n = 866) newly registered on the waiting list for heart transplantation between January 2010 and December 2011. We compared outcomes of 80 patients on VA-ECMO at listing to outcomes of the comparison group. In the VA-ECMO group, a Cox proportional hazard model with transplantation as a time dependent variable was used to evaluate the effect of transplantation on survival. Results: Patients on VA-ECMO were more often on ventilator and dialysis and had a higher bilirubin level than other candidates. One-year overall survival rate was lower in candidates from the study group (52.2%) compared with comparison group (75.5%), (P < 0.01). One-year posttransplant survival was 70% in the VA-ECMO group and 81% in comparison group (P = 0.06). In the VA-ECMO group, transplantation was associated with a lower risk of mortality (hazard ratio, 0.44; 95% confidence interval, 0.2-0.9). Conclusions: Transplantation provides a survival benefit in listed patients on VA-ECMO even if posttransplant survival remains inferior than for patients without VA-ECMO. Transplantation may be considered to be an acceptable primary therapy in selected patients on VA-ECMO.
Article
In advanced cardiogenic shock, early mechanical circulatory support may prevent multiorgan failure and death. In this article, we are describing our experience with extracorporeal membrane oxygenation (ECMO) application. Venoarterial ECMO has been used successfully as a therapeutic option for patients with advanced cardiogenic shock and cardiac arrest. In this review, based on the daily routine of the Hershey group using ECMO for therapy of advanced cardiogenic shock, the application of ECMO is described. The aim is to share our hands-on experience during emergent implantation and to contribute to the knowledge within the field of mechanical circulatory support.
The future of the adult heart allocation system in the United States
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