CDH-ECMO - VV vs. VA - Repair on ECMO: Update Course 2015
hosted by Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Currently the institution does VA ECMO for CDH patients
One institution performs VV ECMO with cephalad cannula for CDH patients and has been doing so since the late 1990s
Conversion from VV to VA ECMO is exceedingly rare at this institution, approximately 3 cases in the last 10 years
If an institution is really good at VV ECMO, they should do VV ECMO; if really good at VA ECMO, they should do VA ECMO
For underlay patches, SIS is used; for full patches, a composite of SIS on the abdominal side and Gore-Tex on the thoracic side is used
The SIS underlay is secured by taking bites of the diaphragmatic leaf and mesh and tying, which causes some imbrication
The Gore-Tex provides the security on the thoracic side, not the SIS
Muscle flaps cause some abdominal wall weakness but not a true hernia because the transversus abdominus muscle is used as the flap
Muscle flaps have not been found to cause a significant amount of scoliosis, no more than any other repair method
Most CDH patients have issues with scoliosis when sutures are taken around the ribs and bite into the intercostal tissue, causing skeletal defects
The risk of skeletal deformity is higher with patches
During thoracoscopic repair, transient respiratory acidosis may occur but its clinical significance needs to be evaluated if it is not too severe
For thoracoscopic CDH repair, very low insufflation pressures are used, with the highest being about 5 mmHg
Once the viscera is reduced during thoracoscopic repair, insufflation can be turned off because pulmonary hypoplasia provides adequate domain without gas
The period of insufflation during thoracoscopic CDH repair should be very short
Aggressive hemofiltration and other measures can obviate some of the renal complications associated with VV ECMO
If you have expertise in VA ECMO, you will not get as good results with VV ECMO and vice versa
You should do what you are good at regarding ECMO modality unless there is overwhelming evidence for one approach
For really poor prognosis CDH patients, aggressive repair in the first 24 to 48 hours on ECMO is performed
For acute pulmonary hypertension crisis cases expected to be a short ECMO run, repair is delayed until off ECMO once echoes demonstrate subsystemic pulmonary hypertension
For patients on ECMO for 2 or 3 weeks, repair is performed towards the end of the ECMO run
The problem in CDH is not the hole in the diaphragm; that is not causing the pulmonary problems
Some institutions will stop ECMO and not repair CDH in patients who cannot be weaned from ECMO
A scope is put in every CDH patient after ECMO at this institution
Muscle flap mobilization and placement can potentially be done laparoscopically
There is evidence that the complication rate with VA ECMO is higher than VV ECMO
VA ECMO is associated with more neurological complications compared to VV ECMO
VV ECMO is associated with more renal complications compared to VA ECMO
In the ELSO registry for CDH, VA ECMO had 48% survival and VV ECMO had 43% survival, with no statistically significant difference
A propensity-matched analysis of the ELSO registry showed a survival advantage for VV ECMO over VA ECMO in CDH patients
There is some data suggesting VV ECMO is probably advantageous over VA ECMO
Data from Texas Children's Group shows that early repair on ECMO versus off ECMO does not have statistically significant difference in outcomes, though curves suggest a tendency favoring post-ECMO repair
After ECMO, most people will do open CDH repair