VP-ECMO: Right atrial/pulmonary artery cannulation has the advantage of providing transpulmonary blood flow independent of right ventricle performance in patients with ARDS, who are prone to abnormal RV and pulmonary vascular biomechanics.
At Penn Medicine, specialists in cardiothoracic surgery, transplant surgery, and critical care are advancing ECMO techniques, indications, and populations served.
An advanced treatment option, ECMO was introduced at Penn Medicine more than a decade ago, initially as a bridging strategy for patients with severe end-stage lung disease awaiting lung transplantation, and to support patients with cardiac dysfunction after open surgery. However, with the confluence of evolving technology and research, and the advent of the COVID epidemic in 2020, the Penn ECMO Program realized a dramatic increase in both the need for ECMO and its potential to offer life-saving intervention in previously unserved populations and disease states.
Consequently, from a beginning that saw eight patients bridged to lung transplantation on ECMO support in a year’s time, Penn Medicine now averages 200 to 250 cases of ECMO support each year for pulmonary and cardiac conditions.
Advances in ECMO Technique and Technology
In addition to the rising number of supported patients, the Penn ECMO Program has evolved, with advances in technology in recent years including new centrifugal and axial-flow pumps, polymethylpentene membrane oxygenators, and smaller cannulas. These introductions have made it possible to incorporate ECMO into the treatment of a wider variety of patients, to allow for a vast expansion in the time patients can remain on ECMO (now up to six months at Penn), to offer additional therapies, and to permit a greater number of patients to reach transplantation.
Penn Medicine has been a pioneer in introducing adjunct devices to ECMO. These include ECMO combined with right ventricular support (Oxy-RVADs) as bridging mechanisms for transplantation, and ECMO as a bridge to LVADS for long-term mechanical circulatory support and recovery.
New Applications, New Populations for ECMO
ECMO has evolved at Penn Medicine beyond bridge to lung transplant to include an increasing number of patient populations and disease states.
Heart
Bridge to LVAD | Cardiac Arrest - ECMO as a bridge to LVADs for left ventricular support, and Oxy-RVAD devices, which support the right ventricle, are now mainstays at Penn for bridging therapy in patients with advanced acute or chronic cardiac conditions and ventricular failure. In addition, extracorporeal cardiopulmonary resuscitation (ECPR), a form of ECMO, is now in use in patients with cardiac arrest who have not responded to conventional cardiopulmonary resuscitation, and in patients with pulmonary embolism.
Lung
Bridge-to-Lung-Transplant - ECMO as bridge-to-lung-transplant remains a keystone therapy at Penn Medicine. The objectives at Penn for critically ill patients on ECMO include support for lung function and improvement of muscle strength through physical therapy and early ambulation. Ambulatory ECMO can turn the bridge period from a risky waiting time into an opportunity for active rehabilitation and prevention of deconditioning. Studies suggest that the long-term survival of lung transplant patients a year following ECMO is comparable to that of patients who did not need perioperative ECMO support.
Lung Rescue - The thriving Lung Rescue Mobile ECMO Program (see the Mobile ECMO for Lung Rescue in Pregnancy Clinical Briefing for more information) has transported >700 patients since its inception in 2014. Notably, since this time, the survival rate for mobile venovenous (VV) ECMO at Penn Lung Rescue has exceeded the Extracorporeal Life Support Organization (ELSO) average, including the pandemic years 2020-2022.
Pulmonary Embolism - With close to 80 patients supported in the presence of massive pulmonary embolism, Penn has one of the largest uses in the world for ECMO in pulmonary embolism as a bridge to recovery or percutaneous or surgical embolectomy.
COVID-Related ARDS - Penn Medicine is now the third leading transplant center in the country for patients on ECMO support experiencing COVID-related ARDS (CARDS). A cause of irreversible lung injury and acute right ventricle injury, ARDs is also associated with a heightened risk for coagulopathies, infections, multi-organ failure, and other complications among patients on ECMO support. As a consequence, prior to 2020, lung transplant was rarely offered to ECMO patients with ARDS.
This practice was modified at Penn Medicine and elsewhere following the arrival of the COVID pandemic in 2020. Three years later, a Penn ECMO Program study determined that one-year survival post-lung transplant for patients on ECMO for COVID-19 lung failure is similar to that of patients with non-COVID-19 restrictive lung failure, and that prolonged pre-transplant ECMO support had the potential to confer adequate clinical and functional status post-transplant.
Case Study
Before his double lung transplant, JP signals his okay to proceed from his bedside at the Penn Pavilion.
JP, a 32-year-old male, arrived at Penn Presbyterian Medical Center (PPMC) via Penn Lung Rescue Mobile ECMO after a month-long induced coma at a regional hospital. Six weeks prior to his hospitalization, JP had been treated with bleomycin for cancer, leading to a delayed compromise in kidney function and the acute onset of interstitial edema and pulmonary fibrosis.
Following a contact from the outside hospital, the Penn Rescue team determined that JP was a suitable candidate for transfer, and he was transported on mobile VV-ECMO to PPMC, where he received corticosteroids as a bridge to pulmonary recovery.
However, over the next few days, his lung function continued to decline. With bridge to recovery now uncertain, JP’s best hope lay with a lung transplant, and he was transitioned from VV-ECMO to veno-pulmonary (VP) ECMO. A form of right ventricular support, VP-ECMO reinforces both heart and lung function, and was necessary in JP’s tenuous circumstances to avoid kidney failure, an exclusion to lung transplant.
JP with his wife and daughter after 2 months on ECMO support and a double lung transplant.
Being awake is another necessity in lung transplant, and soon afterward, the ECMO team was able to bring JP out of his coma. In the days thereafter, he was mobilized on ECMO and began an exercise program to reverse the deconditioning he’d experienced during his prolonged sedation as a preventative for post-operative critical illness and complications.
During this time, JP’s pulmonary function remained negligible, but his kidneys stabilized, and with no prevailing contraindications, he was listed for a lung transplant. Soon afterward, he was transferred on mobile ECMO from PPMC to the Penn Pavilion, and he was able to acknowledge his willingness for lung transplant. Several weeks later, he had a successful bilateral lung transplant.
Three days after his surgery, JP was removed from ECMO support, having spent two months on the machine, and with restored pulmonary function, began walking around the Pavilion floor. A month later he was discharged and cleared to go home to his family, avoiding the need for more rehabilitation at another facility. He has since returned to full-time work.
About the Penn Heart and Vascular ECMO Program
The renowned cardiothoracic, pulmonary, vascular and transplant surgeons and support staff on the Penn Heart and Vascular ECMO team employ the most advanced treatment options and therapies available to provide comprehensive, high-quality, patient-centered care for patients with end-stage heart and lung disease awaiting transplant, or as a bridge to recovery.
ECMO Team
Anesthesia Critical Care/Mobile ECMO
CT Surgery
*Dr Szeto is affiliated with the Penn Mobile ECMO Program, as well.