Cardiology

Biography

Biography: Louis Samuels

Abstract

Acute Cardio-Respirtory Failure refractory to conventional therapy has been perceived of as a therapeutic exercise in futiluty for over half a century. In the 1950s, cardiopulmonary bypass (CPB) was introduced by Dr. John Gibbon Jr at Thomas Jefferson Hospital in Philadelphia, PA. While the use of CPB for surgical procedures has flourished, important “spin-off” technologies began to be conceived of and considered for use beyond the operating room—hence, Extra-Corporeal Membrane Oxygenation (ECMO). ECMO came into existence approximately four decades ago primarily through the efforts of its pioneers Drs. JD Hill and Robert Bartlett. However painful and disappointing the results were initially (and for several decades thereafter) these investigators and others persisted in the belief that this technology was life-saving and not likely to be discarded.rnIn 1983, only three institutions regularly performed ECMO (Medical College of VA, University of Michigan, and University of Pittsburgh). By 1986, nineteen institutions provided ECMO support for neonates. And by 1989, the Extra-Corporeal Life Support Organization (ELSO) was established. It would take another two decades before ECMO for adults was more formally adopted, particularly for respiratory failure. In 2009, two important events occurred: 1) The CESAR Trial was published and 2) The H1N1 Flu epidemic. The CESAR Trial compared ECMO therapy versus Conventional Ventilatory Support for respiratory failure and showed superior outcomes in the former. At the same time, the treatment for ARDS related to the Flu epidemic also showed improved outcomes with ECMO support. As a result of these findings, rescue ECMO therapy for respiratory failure in a variety of clinical conditions (i.e. pre- and post-lung transplant, sepsis etc.) has exploded in popularity. Similar findings began to be observed in the cardiac failure categories, both medical (e.g. AMI-Shock) and surgical (e.g. Post-Cardiotomy Shock).rnAs of 2014, there are 278 ECMO Centers that are members of and report to the ELSO Organization. The number of cases for calendar year 2014 was 6510! The latest ELSO Registry Data (July 2015) reported that—for adults—the survival for Respiratory, Cardiac, and E-CPR ECMO were 58%, 42%, and 30% respectively. These results, compared to the outcomes four decades earlier, represent a monumental improvement with every reason to believe that further success is ahead.rnAmong the reasons for continued opimism with ECMO therapy is the progress made in education and technology. With the help of the ELSO Organization, data driven quality measures are being reported and presented at national and international meetings. Every aspect of ECMO application is being critiqued, including patient selection, technical issues, and post-cannulation managment. Furthermore, commercial industry has contributed to marked improvements in the device itself, particularly the pump-oxygenator unit along with the monitoring safeguards that go along with it. Lastly, innovative strategies combining ECMO with other tecnologies—hybrid mechanical support-- may prove worthwhile in selected cases.rnIn summary, ECMO in general and Adult ECMO in particular is emerging as something much more than an exercise in futility. It is evolving into a standard of care for acute cardio-respiratory failure refractory to conventional therapies.