No disclosures Pediatric Artificial Lung (PAL) Work sponsored by NIH RO1-HD-015434 Ronald B. Hirschl, M.D. Professor and Head, Pediatric Surgery Mott Children’s Hospital University of Michigan Pediatric Chronic Respiratory Failure Pediatric Chronic Respiratory Failure • Hypoxemia, CO 2 retention, and pulmonary hypertension. • ECMO is being • CDH, BPD, ACD, interstitial lung discontinued for futility disease, and fibrosis following at a lower rate which is necrotizing pneumonia and ARDS. resulting in longer runs. • CDH: • Johns Hopkins—Case 56% die or meet criteria for BPD at 30 days. of ECMO 605 days The cost of CDH is $250 million annually with survival • 974 adult ELSO Registry with respiratory Beyond age 4-5 years patients lead reasonably normal lives. failure from 1989 to 2013 Example: LTx in newborn with CDH and excised at 5 years. • ECLS course > 14 days, median course of 21 days (range: 14-208 days). DeAnda A , et al. J Ped Surg, 33:655, 1998 Posluszny J, et al. Ann Surg 263:573, 2016
Pediatric Chronic Respiratory Failure Pediatric Chronic Respiratory Failure • LTx common for cystic fibrosis in older children • LTx rare in ARDS on ECMO and in • ECMO is complicated, labor newborns/infants with refractory PHTN intensive, and expensive. • 27% of pediatric LTx performed in children < 11 • ECMO mortality is 26% in years of age and ~3% in infants < 1 year of age neonates and 43% in children • A simple PAL might : Provide gas exchange, offload the RV, decrease pulmonary pressures Allow discharge from the ICU and even potentially to home. • Eventually may serve as a destination device. Brendan C, et al. J Heart Lung Transplant. 32:989, 2013 Puri V, et al. JTCVS. 140:427, 2010 Aurora P, et al. J Heart Lung Transplant 29:1129, 2010 Lung Transplant in Pediatric Chronic PA LA in Pulmonary HTN Respiratory Failure • PAL would permit extubation, ambulation 60 600 • Allow months to recover from acute disease and 50 500 deconditioning 40 400 • Provide a contingency for graft failure PCO2, mmHg PO2, mmHg PVR (mPAP-mLAP/CO) 30 11 300 10 N = 26, 80% Surv 9 20 200 8 • 4 year old Wood's Units 7 PCO2 10 100 • BMPR2 6 PO2 N = 34, 50% Surv 5 mutation 0 4 0 3 • PAH B1 B2 1 2 3 4 5 6 7 2 • RA Ao Elapsed Time, Day 1 0 Device Clamped Device Flow Schmid F, et al., Ped Pulm 51:1222, 2016 Mean PVR: 5.91 to 2.64 Woods Units, p=.001 Fuehner, T., et al., AJRCCM, 185:763, 2012 Sato, Ann Thor Surg. 84:988, 2007 Wong, JYW, et al., Am J Transplant, 15: 2256, 2015
Pediatric Artificial Lung • Total gas exchange requirements of • High efficiency patient • Low resistance • Unload right ventricle • Simple, no pump • Minimize blood element trauma • Serve as bridge to lung transplantation, recovery, destination PAL • 30 year old • 38 year old • PAH and PVOD • PAH and RHF Management of • ECMO 62 days • ECMO 18 days PAH PA-LA PA-LA • Bridge to • Succumbed to double LTx sepsis Strueber M, et al. Am J Transplant 9: 853–857, 2009 Camboni D, et al. ASAIO Journal 55: 304, 2009 Pediatric paracorporeal lung assist device • 4 patients supported with pulmonary artery to ECMO Lung device Extubated (days left atrium lung assist device support support post device Age Diagnosis (days) (days) insertion) Outcome • One neonate and 3 children under the age of 2 death (hemorrhagic 23 days ACD 5 54 15 CVA 44 days) AV canal, R lung death (renal preop Preop PASP during 2 months hypoplasia 0.1 74 72 failure,CVA) PASP* SBP device support** Percent drop in 9 months ACD 9 5 n/a lung transplant Age Diagnosis (mmHg) (mmHg) (mmHg) PASP weaned to medical 23 days ACD 75 50 55 27% management, mild AV canal, R lung 23 months PPH 17 23 9 CVA 2 months hypoplasia 125 85 51 59% 9 months ACD 100 75 46 54% ACD, alveolar capillary dysplasia; AV canal, atrioventricular canal; PPH, primary 23 pulmonary hypertension months PPH 93 75 not measured n/a Hogansen, D, et al. J Thor Cardiovasc Surg 147:420, 2014 Hogansen, D, et al. J Thor Cardiovasc Surg 147:420, 2014
Left atrial cannulation Pediatric paracorporeal lung assist device strategy with transatrial Patient Left atrial cannula LA thrombus graft 23months 22F metal R angle none 23 days 16F metal R angle large 3 months 16F metal R angle small 9 months 10mm Gore graft none Berlin cannula with transatrial • Guidelines for implantation and management of Gore graft sewn to paracorporeal lung assist device in children interatrial septum • Current indications: primary or secondary Berlin cannula to pulmonary hypertension with systemic or main pulmonary suprasystemic PA pressures. artery Hogansen, D, et al. J Thor Cardiovasc Surg 147:420, 2014 Gazit A, et al.Ped Transplant 20:256, 2016 Pediatric Artificial Lung: Pediatric Artificial Lung: Ovine Model of Pulmonary Hypertension Ovine Model of Pediatric Lung Failure • Five lambs (29.4 ± 3.1 kg), left thoracotomy. Pathophysiology • 10 mm grafts sewn onto PA and LA and connected by a shunt, tourniquet on the right PA • The next day, baseline data collected • The right PA was then occluded and data collected • PAL (Novalung) attached and data collected • Seven (25-40 Kg) sheep • Thoracotomy with RPA tourniquet placement • Occlusion of RPA on POD #1 Alghanem F, et al. ASAIO J 63:223, 2017 Trahanas, J, et al.ASAIO Journal 2017; 63:216–222
Pediatric Artificial Lung: M Lung Design Ovine Model of Pulmonary Hypertension CFD Particle Image Velocimetry Alghanem F, et al. ASAIO J 63:223, 2017 Fiber SA = 0.28 m 2 M Lung Design M Lung Efficiency
Nitric Oxide Surface Coating With S-nitroso-N- acetylpenicillamine (SNAP) Prevents Platelet PAL Servoregulation of CO 2 Consumption and Clot Formation During ECLS • NO donor mimics range of endothelium NO release • 8 rabbit AV ECLS no heparin, n=4 control, n=4 SNAP • Platelets at 64% of baseline (control = 12%) • 67% reduction in circuit chamber thrombus formation • Automatically controls gas flow based on exhaust gas CO 2 . • Proportional-integral-derivative (PID) feedback controller to modulate the sweep flow • A graphical user interface and software controller were programmed using Microsoft Visual Brisbois EJ, et al. Acta Biomaterialia 37:111, 2016 Those that do the work Cannula Development
Pediatric Chronic Respiratory Failure • Survival is ~50% at 5 years in pediatric lung txp Brendan C, et al. J Heart Lung Transplant. 32:989, 2013
Recommend
More recommend
