CDH-ECMO - VV vs. VA - Repair on ECMO: Update Course 2015

So this kid's a little bit sicker than the last one on dopamine. Uh, echo shows super systemic pressures. You mentioned, I mentioned oxygenation index of 45. So the kid's looking like they need to go on ECMO. They get to your NICU, what do you do? Currently we do VA ECMO, but I don't, I, I understand the benefits of VVECMO, and it's certainly a plausible approach so. I don't do ECMO anymore. I don't know what really what my institution does that. So I would tell you that in our institution, what would happen is the kid would get a trial of inhaled nitric oxide and then we would go on VVECMO and then how do you convert from V to VA, right? So we, uh, it's very exceedingly rarely. So we do VV ECMO with cephalide cannula. I mean, for those of you familiar with our ECMO program, we, we've been doing VVECMO for, you know, since the late 90s. And we, you know, I, I think that we, we have good results with it, and we rarely, rarely, it's, I, I want to say it's 3 in the last 10 years or something like that that we converted from, but I don't know. VA to VV OK, I think that's an institution thing. I think there are a number of institutions that are VV pro VV and a number that have struggled to convert, but it certainly has its benefits. I think it's one of those things that somebody mentioned before. If you're really good at VV ECMO, do VV ECMO. If you're really good at VA ECMO, do VA ECMO. But there is some evidence. That the, the, you know, that the, the complication rate with VA ECMO is higher than VV ECMO. So, um, I know we're gonna go fast, but there's a bunch of questions and we want to do this in a few minutes. But Federico asked, uh, Federico, if you could clarify your question, you asked what type of mesh. I think you, I, I don't know which, if you're talking about when he does the, when he needs a patch or if he does an underlay. Um, so the underlay we use SIS, and, and for the uh for a, for a full patch we use we use SIS on the underlay on the bottom and Gore-Tex on the thoracic side. So we do a composite for so how do you get the SIS on the Die for on the abdominal side when you're in the chest, so you, you just, how do you keep it there? You lay it out and, and do an underlay, and if it's on the side, you can just sort of tack it to the sides. So you tack it, you, you take a bite of the diaphragmatic leaf and then a bite of the mesh and tie. And you can go or you know so it'll, it'll, it'll imbricate, it'll imbricate a little bit, a little bit, but you're not if there's a gap, you do it that way, but you can do it and you don't need much. The SIS, it's not like that's not the security, it's the Gore-Tex that's going to give you the secure on the side. So you go attack it so that it's not going to flip around or move around. So if you're doing a primary with an underlay, you go sort of in. And back in uh in back out into the chest again, so chest, abdomen, chest. Through the upper leaf or whatever, yes, um. All right, well you're trying to find that, the next question, so I guess this would be for Dan and for Jason, uh, muscle flaps, does it cause a lot of, uh, scoliosis and chest deformities? There is some abdominal wall weakness. It's not a true hernia because you're using your transversus abdominus muscle as your flap that you. Lay into the defect. We have not found a significant amount of scoliosis, more so than any other way of repair, because I think most of these patients have issues with scoliosis when you're taking those sutures around the ribs and biting into the pericostal tissue. I think it all causes some skeletal defects. Yeah, I think the risk of skeletal deformity is higher with patches so that would be OK. Um, uh, there was a question about what about respiratory acidosis during thoracoscopic repair in formerally very sick patients. So this is the one I get off ECMO, yeah, you know, the question is what's there, I think it's something we need to look at, uh, and the question is what's the clinical significance of that acidosis if it's a transient acidosis and it's not too severe. Again, you need to work with your anesthesiologist to make sure that, you know, that the entitled CO2 is not all of a sudden, you know, 75. And you need to work with them. Usually, you know, it's interesting, it's usually not much of a problem because you can use the gas. The gas will help you reduce the viscera. And once the viscera is in, you can even come off. So we use very low pressures. The highest probably is about 5, but then actually once it's reduced, and especially if you can get the spleen down and it acts as a nice cap, uh, you can actually turn off the insufflation because there's usually plenty of domain because you have pulmonary hypoplasia, you don't need much gas. So it should be a very short period of time while you're doing that and you don't need to use real high pressures at all. OK, uh, Cynthia wanted to, Reyes wanted to just talk, you know, make sure we don't do VA lightly, that the implications of carotid artery ligation. Well, and, and I got a, I have a slide here that we're gonna come. I was gonna say, so who does, and I was just gonna ask, we have a poll question just in general, who does mostly VA versus mostly VV ECMO just to poll the audience to see how much we do? And do we have the poll up for the, for the folks. Out there, let me look. Let's see here. Well, we're putting that up, but you can look at this, uh, data and see if this is just one of what people do. But these are 3 studies, uh, looking at VA versus VVACMO. VA is associated with in the top one, VA is associated with more neurological complications. VV is associated with more renal complications. Um, although if you're very aggressive with, uh, hemofiltration and other things, I think you can obviate some of the renal complications. In the Elsa registry looking at overall survival, you know, there was no significant statistically significant difference, but you know, VA had a little, this is diaphragms. VA ECMO had a 48% survival. VV had a 43% survival, but we don't know the characteristics of any of those patients, so it's hard to talk. About the last study here is that it was also of the ESO registry, but it's a propensity analysis and basically looking at VV survival versus VA survival and a propensity analysis where they try whether you match the patients and that actually showed an advantage for VV ECMO. Uh, you get the slide again. Yeah, let's put the slide up there again. VA versus VV. And you know, the main one to look at, I think, is the is the bottom one. So there is some, some data that VV ACM probably is advantageous. So Next poll question, unless there's any comments on VA versus VV. So I'll just say that You trained me, Mark, and um I'm used to VV ECMO from from Eggleston, but going into practice, nobody that I work with is used to VV ECMO and so that's why it was changed to VA because I don't run the circuit. I obtain circulation for them, but then let them maintain it. Well, and that's what I was saying before, you know, if you have expertise, if you're really good at VA ECMO, you're, you're, you're not going to get as good a results with VV ECMO and and vice versa. I mean, I think that it's, you got, you should do what you're good at. I mean, if there's overwhelming evidence that VV ECMO is the way to go, then maybe we should all learn how to do it. But, you know, until then, the evidence is leaning that way. So, real quick question, timing of repair, uh, on ECMO early and run, on EC mode just before you're ready to come off, off ECMO open, off ECMO MIS. And we can get the polling. The polls are already up. Before I say them, what does everyone here want to do? I think this is the one in a million dollar questions that no one can answer. I've changed my practice throughout my time in Cincinnati, and now for the really poor prognosis patients, we're aggressive in fixing in the 1st 24 to 48 hours on ECMO. If we think this is a An acute pulmonary pulmonary hypertension crisis and will be a short run. We'll wait to get off ECMO and repair once we get echoes demonstrating subsystemic pulmonary hypertension and for the patient that's on for 2 or 3 weeks and we're stuck in a rock and a hard place, we'll fix it towards the end of our run. I mean, unless you have shift from your guts in the chest. to me it doesn't make sense because again, the problem's not the hole in the diaphragm, that's not causing your pulmonary problems. If you put the slide up, this is data from a paper from the Texas Children's Group and the curves are different, but it's not statistically different, basically saying that that there's that early repair on ECMO does not, uh, in other words, on ECMO versus off ECMO. Uh, doesn't really have much difference, although there is a big, there's a tendency there on those curves to say that after you're done with your ECMO run, our, our group, we will actually, if we have a kid that we've had kids that can't, we can't get off ECMO, and we, we, we just stopped. And we don't fix them. That's a, that's a that's a long discussion to have. I don't, I'm not gonna throw that in here, but we're running, but we have that, yeah. So after ECMO, we sort of already covered that after ECMO, I think most people, it sounds like we'll do open up. We'll put a scope in everybody. We can put that poll up there for the audience. And then lastly, uh, what kind of patch. Do people use biologic, PTFE or like like we do using PTFE and and a bio bio or other permanent graft and a manufactured composite. Some people use things, you know, that's that's already manufactured, I think like Duosh and some of the others, and then, you know, we do the two separate patches of biologic and permanent. We can put those poles up there, yeah, and add muscle because, yeah, I didn't put, I didn't put muscle to add that as a true biologic. So yeah, so now I'm gonna go home and try to figure out a way to do that with a scope because I think you can do it. I think you can do it laparoscopically. You can mobilize the, you can mobilize it laparoscopically and flip it down, yeah, but we'll work on that. But yeah, it's gonna be tough, huh, yeah. So any other uh questions, comments? Told you it's not a very controversial topic. I thought that was a great summary, and you've hit on the, the major controversies. I think I, I was, and I think I'm interested to go back and see the final results of these polls and maybe publish them. All right, thank you, Mark. Sure.