J Thorac Cardiovasc Surg 1996;112:206-207
© 1996 Mosby, Inc.
A simple switching technique from cardiopulmonary bypass to a long-term extracorporeal life support system
Junichi Utoh, MD,
Hiraaki Goto, MD,
Kohichi Ashimura, MS,
Kazufumi Okamoto, MD,
Hidenori Terasaki, MD
Department of Surgery
Intensive Care Unit
Department of Anesthesiology
Kumamoto University School of Medicine
Kumamoto, Japan
To the Editor:
We read with great interest the article by Muehrcke and associates
1 in the September 1995 issue of the Journal. 1 They summarized their clinical experiences with an extracorporeal life support (ECLS) system and reported that limb ischemia was the most common complication, found in 70% of patients who underwent percutaneous ECLS. Besides limb ischemia, bleeding from the surgical wound is also a life-threatening complication of ECLS. 1,2 Since 1965 we have used ECLS in more than 60 patients with severe cardiopulmonary failure. 3,4 To overcome the aforementioned problems, we recently began routinely using the following technique (Fig(Fig. 1).
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Fig. 1. A cannulation technique to switch from CPB to ECLS for postcardiotomy cardiac failure. A Dacron vascular graft is sutured to the right femoral artery. A 12F wire-reinforced cannula is inserted through the saphenous vein to the distal femoral vein. A 21F heparin-bonded cannula is inserted through the femoral vein to the right atrium. The lines are connected to a heparin-bonded ECLS system. The CPB flow is decreased and the ECLS flow is increased to allow the switch. A, artery; V, vein.
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When a patient is difficult to wean from cardiopulmonary bypass (CPB) because of cardiac failure, an intraaortic balloon pump is initially inserted in the left femoral artery after an 8 mm sealed Dacron prosthesis has been sutured to the left femoral artery in an end-to-side fashion. The intraaortic balloon pump is started in a 1:1 mode. The ECLS is set up during CPB. The entire system is heparin-bonded and composed of a capillary membrane oxygenator (Maxima: CB1380, Medtronic Inc., Cardiopulmonary Div., Anaheim, Calif.), a Bio-Medicus model 540T centrifugal pump (Medtronic Bio-Medicus, Eden Prairie, Minn.), and tubes and connectors. Our switching procedure is illustrated in Fig. 1. The right femoral artery and vein are taped. A second 8 mm sealed Dacron prosthesis is sutured to the femoral artery in an end-to-side fashion and then connected to the arterial line of the ECLS system. A 12F wire-reinforced cannula is inserted through the saphenous vein to the distal femoral vein and fixed with 3-0 silk. The CPB flow is decreased 50% and the inferior vena caval cannula used for CPB is removed. A 21F heparin-bonded wire-reinforced cannula with multiple side holes (Medtronic) is inserted through the femoral vein to the right atrium and fixed with two Teflon tapes with double ligation. The two venous cannulas are connected to the ECLS system with a Y-shaped heparin-bonded connector. The ECLS flow is started and slowly increased as the CPB flow is slowly decreased and then stopped. The superior vena caval cannula used for CPB is then removed. Teflon tapes that were placed around the femoral artery and vein are loosely tied, cut short, and left in the wound so that the vessels can be easily found during the second-look operation. Both Dacron grafts are left in the subcutaneous space. One gram of kanamycin powder is placed on the wound and the wound is closed.
In case of perioperative myocardial infarction, we consider the combination of ECLS and intraaortic balloon pumping to be the best means to unload the heart and augment coronary flow so that the stunned myocardium can rest and recover from the acute ischemic injury. 4 The present technique provides the following advantages: (1) Myocardial damage is avoided and systemic circulation is maintained while mechanical support is set up; (2) ischemic or congestive complications of the lower leg are lessened; (3) massive bleeding, which is the most serious complication of ECLS, is infrequent 2; (We have recently stopped using heparin and now use nafamostat mesilate applied to the inflow of the centrifugal pump to achieve an activated clotting time of 140 seconds. This system can run for 48 to 72 hours without fibrin clot formation or thromboembolic complications.); (4) fewer complications are caused by reopening the chest or mediastinum, which necessitates general anesthesia. Only local anesthesia and simple surgical techniques are necessary to remove the cannulas in our method.
ECLS is a reasonable mechanical support system for postcardiotomy cardiac failure, especially in the case of perioperative myocardial infarction. Our technique is recommended to allow easy weaning from CPB and to safely maintain long-term mechanical support.
References
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Muehrcke DD, McCarthy PM, Stewart RW, Seshagiri S, Ogella DA, Foster RC, et al. Complications of extracorporeal life support systems using heparin-bound surfaces. J THORAC CARDIOVASC SURG 1995;110:843-51.[Abstract/Free Full Text]
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Anderson H, Steimle C, Shapiro M, et al. Extracorporeal life support for adult cardiorespiratory failure. Surgery 1993;114:161-73.[Medline]
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Terasaki H, Morioka T. Extracorporeal life support: present status and the future. Ann Acad Med Singapore 1994;23(Suppl):33S-9S.
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Kurose M, Okamoto K, Sato T, Kukita I, Taki K, Goto H. Emergency and long-term extracorporeal life support following acute myocardial infarction. Clin Cardiol 1994;17:552-7.[Medline]
