Application of extracorporeal membrane oxygenation in the treatment of acute myocarditis

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Extracorporeal membrane oxygenation (ECMO) is a technique that temporarily supports cardiopulmonary function by an artificial cardiopulmonary system. This technique is used on patients with respiratory and circulatory failure, especially myocarditis, to help patients overcome critical conditions, and to give the heart and lungs time to rest and recover.

1. What is extracorporeal membrane oxygenation?

Extracorporeal membrane oxygenation (ECMO) is a method of circulatory and respiratory support when both of these functions cannot function properly. ECMO technology works to replace heart or lung activity, or both, for a short period of time.
ECMO technique helps to bring blood out of the body, remove CO2 and add O2 to red blood cells, then return O2-rich blood back to the body. Therefore, this technology is used in cases of heart failure, severe respiratory failure, even apnea to give doctors time to find the cause and provide treatment.
ECMO is widely used in young children, especially infants. However, adults with heart failure, respiratory failure, or heart conditions that interfere with breathing, circulation, and are life-threatening can use ECMO.

2. Application of extracorporeal membrane oxygenation in the treatment of acute myocarditis

Myocarditis is a disease with rapid and complex progression, which is life-threatening if not treated early and promptly. The initial signs of the disease are atypical, similar to the common cold. Patients present with fatigue, body aches, and loss of appetite. These symptoms are relatively mild, so they often make the patient subjective. However, the course of the disease is very rapid, only after a few days from the time the initial symptoms appear. Patients will develop acute symptoms including chest tightness, shortness of breath, tachycardia, hypotension, weak pulse leading to serious complications such as respiratory failure, circulatory failure, cardiac arrhythmia, inflammation lung.
In cases where the patient is hospitalized with fulminant form, the indications for treatment such as respiratory support, use of vasopressors, antiarrhythmic drugs are almost unresponsive. Accordingly, supporting respiration and circulation by pericardial oxygenation is the only option left that can help revive the patient. ECMO acts as an artificial heart, lung, and active hypothermia to protect the brain; Continuous dialysis to support the liver and kidneys helps maintain the patient's life, and at the same time gives the heart time to rest and recover.
After being supported by pericardial oxygenation, the patient has time to respond to vasopressors, antiarrhythmic drugs that at the time of acute manifestation of the disease do not respond and there is time for the heart and lungs to be treated. rest and recuperate.
In addition to myocarditis, ECMO is also applied in all other diseases leading to respiratory and circulatory failure such as:
Support after heart surgery, after coronary artery bypass surgery, placement of ventricular assist devices Heart failure Acute heart failure refractory to medical therapy with maximum catecholamine dose: Adrenalin > 4 μg/min Dopamine or Dobutamine > 20 μg/kg/min Acute respiratory distress syndrome (ARDS) Pneumonia (viral, bacterial, pneumonia) aspiration) Pulmonary dysfunction after organ transplantation Pulmonary edema after pneumonectomy Cardiogenic shock Cardiac arrest

3. Methods of treating myocarditis with ECMO

The two most common types of ECMO are venous-arterial (V-A ECMO) and venous-venous ECMO (V-V ECMO). ECMO helps blood that is taken outside the body from the venous system to be supplemented with oxygen and then returned to the body. In V-A ECMO, blood is returned to the arterial system and in V-V ECMO blood is returned to the venous system. However, V-V ECMO only supports breathing, not the heart, and V-A ECMO can support both heart and respiration.
3.1 Venous-arterial (V-A ECMO) In veno-arterial method (V-A ECMO), the practitioner places an intravenous catheter into the left or right femoral vein to draw blood out to the side external and an arterial catheter into the left or right femoral artery to return blood to the body. The position of the catheter tip in the right femoral vein was kept immediately near the junction of the inferior vena cava and the right atrium, while the tip of the right femoral artery was in the iliac artery.
3.2 Vein-Venus (V-V ECMO) In veno-venous ECMO (V-V ECMO), the practitioner places a catheter into the femoral vein to drain blood and the right internal jugular vein to return blood.

4. Contraindications of ECMO

Absolute contraindications: People with age > 65 Irreversible heart block Irreversible pulmonary block Chronic severe pulmonary hypertension. Person weighing >140kg Advanced liver disease AIDS Time of cardiac arrest or duration of cardiopulmonary resuscitation cannot be determined for >60 minutes. Relative contraindications: Trauma with multiple bleeding wounds Multi-organ failure Absolute contraindication to the V-V ECMO modality: Severe pulmonary hypertension (mPAP > 50 mmHg) Severe left or right heart failure (EF < 25% ) Patients in cardiac arrest Absolute contraindication to modality V-A ECMO: Aortic aneurysm Severe aortic regurgitation

5. Complications of extracorporeal membrane oxygenation (ECMO)

Neurological: Common consequences in adults treated with ECMO are subarachnoid hemorrhage, infarction, cerebral ischemia, unexplained coma, and brain death. The probability of bleeding is 30-40% due to the continuous infusion of heparin-containing anticoagulants causing platelet dysfunction. Therefore, patients need to be carefully examined and tested before performing ECMO and closely monitored during the operation to ensure safety and timely detect complications. Blood: Blood platelets are reduced by the anticoagulant heparin, to overcome, use anticoagulant without heparin. In addition, there is a retrograde blood flow in the aorta even when the femoral artery and vein are connected to the ECMO machine. If the catheter tip is not maintained in the original position, blood stasis will occur, causing blood clots to appear. Premature birth : Infants under 32 weeks of age should not receive ECMO for survival because the risk of intracranial hemorrhage is very high. Infection: Because it is an oxygen exchange system outside the body membrane and directly connected to the blood vessels in the body, the risk of infection is very high. If not detected and treated promptly, it will lead to the risk of sepsis, affecting the patient's life. Renal failure: Renal failure occurs when the ECMO system does not supply enough blood to the kidneys, usually acute renal failure. Stroke: Caused by an embolism or a system failure to supply and distribute enough blood to certain areas of the brain. ECMO also has the potential to cause injury at catheter sites. Extracorporeal membrane oxygenation ECMO is a medical method that requires doctors and technicians with high professional expertise. Vinmec International General Hospital has successfully applied this method to the treatment process, helping to save the lives of many patients with acute myocarditis.
Besides, the hospital has invested in modern machinery and equipment to support doctors during surgery and patient resuscitation, such as: Maquet's HR20 artificial heart and lung system, Machine breathe GE's R860.

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