Berlin Heart ECMO

So, I wanted to talk about this crazy case that happened on my first week at Vandy, because this is an awesome story of the versatility of Perfusion!
We had a patient that presented with AVcanal defect, with severe mitral and tricuspid regurgitation. This patient came in for AV canal repair, mitral and tricuspid repair. The patient was not doing well after coming off bypass and went on ECMO support. After a few days on ECMO the patient still suffered from severe MR so the patient was brought back to the OR, they were unable to repair the leaky valve, and required an new mitral valve. (FYI they do not make porcine valves for peds patients so it has to be a mechanical valve, and just think how many times you would have to have surgery again to replace the valve as the patient grows bigger. So putting a mechanical valve is a rarity and is avoided at almost all costs).

The first valve was inserted the patient still had issues post bypass and ECMO was continued. They determined that there was an annular leak around the valve and required further repair. Patient was brought back to the OR for repair. Again, issues remained post bypass, and ECMO was still continued. Then issues began to arise with the mechanical valve, it kept getting stuck open, so the patient had wide open MR. The patient was brought back to the OR again for another valve replacement (this was my first case experience at Vandy and was called back to TN from my turkey day vacation in IN to see this case). The patient continued to have arterial saturation issues and ECMO was continued. Finally, the Berlin Heart implantation was decided for this patient. (Also, FYI the Berlin heart is not FDA approved so to use it on a patient requires FDA compassionate use, and they must approve of this before the device can be implanted).

FDA approval comes, and we move forward with implantation. The LVAD was successfully implanted, and about 20 minutes later the patient began to go into right heart failure and the use of an RVAD was required. RVAD implantation was successful, and then the patient sats began to deteriorate again. The surgeon says we have to go back on ECMO, but there is one major problem, this baby is only a few months old, has been put on bypass over 4 different times, has our current bypass cannula in to transfuse volume, these massive inflow and outflow VAD cannula that seriously swallow they entire patients chest cavity, the surgeon has nowhere else to cannulate for ECMO support. After discussion with the Berlin Heart rep and her making several calls to other perfusion teams throughout the US, and determining that the pressure drop across the Quadrox-iD pedi oxygenator was low enough to not hinder the VAD support. We decided to insert the oxygenator into the inflow cannula of the LVAD for ECMO support. You wouldn't think it but it was successful, the patient did well on this type of "ECMO" support.

Unfortunately, the ending to this story is not a happy one, but it really shows that we as Perfusionists have to think on our feet about helping the surgeon keep a patient alive, and believe it or not, know your IFU's and have them available because without those, this wouldn't have been a possible option.

Sonya

Exciting news at Vandy

So the VAD program at Vanderbilt was just initiated in March of 2010, so it is fairly new, but we just had an amazing experience with one special patient. I will post links to this amazing kid below. It is patients like this that truly defines the importance of Perfusion in the medical field.

This is our patients story, who was born with congestive heart failure. It shows a video of him with his Berlin Heart before we knew he was getting a transplant.
http://news.vanderbilt.edu/2011/01/tennessee%E2%80%99s-first-berlin-heart-infant-receives-heart-transplant/

The transplant was a great success, and yes like all transplants it occurred in the wee hours of the morning!

He is doing well and I believe he will be going home in the next couple of days! We will all miss him in the hospital because he was such an amazing little boy!

Sonya Burrell

Monroe Children's at Vanderbilt

So this is a brand new rotation site for hands-on pediatrics and I am the guinea pig. The cardiac team consists of 3 surgeons (one which was just given privileges last week, so don't know how they will be yet). The two I have worked with very rarely get upset in the OR, and lack the "normal" personality of a cardiac surgeon. One of the surgeons I clearly define as a machine, he will operate all day and night without stopping. My first week here I worked over 40 hours on just Monday and Tuesday, finishing the week off at over 70 hours. My first week at Vandy consisted of a redo RV to PA conduit, MV repair with AVSD repair, Fontan, Interrupted aortic arch, Berlin Heart Bi-VAD implantation with Quadrox-ID pediatric oxygenator in line for ECMO support, Glenn shunt, DORV/VSD repair with arterial switch, ASD PAPVR repair, and bidirectional Glenn Shunt....whew that was a lot.

There are 4 perfusionists here, all are great people to work with. The chief perfusionist is not in the OR as much as the other three but he is there in the office daily, and he is a process improvement machine, so if you bring him an idea he wants to know all about it and be prepared to do the research to back up your stuff! This hospital does A LOT of ECMO which unfortunately is not controlled by perfusion right now, but the ECMO program is going under some major changes so who knows! This site is amazing, I have never done the same case twice, they are never routine, and each day is a new challenge. Be prepared to learn a lot but be patient because they are a little slow to let you pump a case, and you really have to prove your worth to sit behind the main seat. They use roller pumps, with terumo circuits, Terumo systems 1 heart-lung machine, and TLINK charting. This center is 100% electronic charting for the patient records so if your used to paper this is going to be a major change for you. Oh and you are on call 100% of the time (yes this includes weekends)!

Nashville is an awesome place to live! For those venturing here in the winter season expect snow instantly turned to ice (and the people here don't know how to drive in it..lol). If you have any questions feel free to email me sonyaburrell1@gmail.com

Sonya

Washington Hospital Center/Johns Hopkins Hospital

I was at Washington Hospital Center from June until January, I pumped 118 cases and had 40 opCAB or Trans-apical/trans-femoral. The staff is great, they are willing to help you out with anything. There are 11 perfusionists (you only work with 5 or 6 of them) the average day was show up at the hospital between 6 and 6:30 set up and get ready for your case. You must be ready because the cardiac team is very fast (example AVR on bypass 50 min, CABGx4 on bypass 45 min, HeartWare HVAD implant, on bypass 62 min). If you are the only student there you can get in at least 2 cases per day. If there are two students there you can get 2 in if you want to stay later. Overall an excellent site. The staff is very interested in the latest technology and is open minded enough to look at other products and materials to achieve better patient outcomes. On Tuesday mornings you are able to go the their cardiac conferences which are very informative. Great rotation site would recommend it to anyone.

I started at Johns Hopkins Hospital just over a week ago. It is so much different. It is a teaching hospital with many medical student and fellows. The cases are much longer and the variety of cases are more in depth. They use roller pumps. You will spend a lot more time at Hopkins, the student MUST be in the OR before 6am! You are also required to pump 2 cases per day. Depending on the day you could get out anywhere between 6pm and 8pm. The staff is very helpful and willing to help you in anyway. I look forward to the remainder of my time at Johns Hopkins Hospital.

Gregory Kitchen

Cedars-Sinai and Primary Children's

I am currently at Cedar-Sinai Medical Center in Los Angeles, CA. Yesterday I was involved in one of the longer cases I've had and figured I could share it on here. It was a Bentall with circ arrest. However, the surgeon wanted me to go on bypass BEFORE he opened the chest. And during circ arrest for opening the chest. Interesting... huh?

Well, he cannulated the axillary artery with a Vascutek 8mm graft and the femoral vein with a 23/25 Estech venous cannula. We went on and cooled to 18 degrees, turned off the pump, and about 3 hours later we were warm and weaned off pump. However, this is not the end. After 2 more pump runs, a CABG, and IABP, it was determined that the patient needed ECMO. In room time: 0715. Out of room time: 0530. 22 hours. On average, there are 15 surgeries/week. Cedars: 10 Perfusionists, 6 surgeons, 3 fellows, a large VAD/Transplant program (#1 Transplant), the PARTNER trial, TEVAR hybrid standby, cell saver for orthopedic surgery and liver transplant coverage with veno-venous. There is usually at least one day/week you will be at the hospital longer than 20 hours and may be expected to be back for the cases the next day. I pumped 60 cases in 3 months.

Primary Children's in Salt Lake City, Utah was phenomenal for pediatrics. I really enjoyed the staff, surgeons and overall "feel" in the OR. I felt comfortable in pumping pediatrics with great Preceptors helping me learn the Peds side of Perfusion. I pumped 66 cases in 3 months.

I agree with a previous post (Bret's) to be prepared for anything when you go into the hospital and know that there is not much of a routine "schedule" in Perfusion.

If you have an questions about either site, please let me know. My email is ariannagrether@gmail.com or call my cell 541-941-3132.

Good Luck! :)

Intermountain Medical Center

IMC is a very new hospital. I think it was built less than five years ago. There are five perfusionists, but you will only be working with four. One of the perfusionists decided that he didn't want to have students. You will work with the guy that is on first call, unless the first call guy is the perfusionist who opted out of working with students (you will then work with the second call guy.) I have been doing one or two cases a day at IMC. There are five different surgeons and the surgeons are great. They are very patient and very easy to work with. IMC just switched from running rollar pumps to centrifugal pumps. They also have run the Quest Microplegia system. Right now they are part of the PARTNER trial and are doing trans-apical and trans-femoral AVR's in the cath lab which are stand by cases for us. If you have any other questions just send me an email or give me a call and I will be more than happy to talk to you about IMC's program.

Bethany Warnke

Swedish Seattle, WA

The number of case that occur each day can range from 0-5. There were only 3 days when I was there that there wasn't any cases. They only allow 1 student to rotate there at a time so if you go there plan on pumping a least 1 case a day. I got over 120 cases in the 6 months that I was there. There are 3 surgeons and 5 perfusionist. They make you take call 1 weekend a month and at least 1 day during the week. On call during the week means that if a surgeon has a to-follow case you would pump both cases. When pumping 2 case in 1 day you will usually be at the hospital from 6am until 8 or 9 at night. The perfusionist are very nice and always willing to help. They use the Terumo System 1 with a centrifugal arterial pump. They do not have a VAD or ECMO program. A typical day would be getting to the hospital around 6am and leaving around 4pm. They just acquired a liver transplant program so I was able to see 1 liver transplant. The surgeons for the liver transplant said they will typically not use veno-venous bypass but there is a perfusionist in the OR room during the surgery with the pump ready. Overall this was a very good site to do my first rotation and I learn alot.


Brian Perfette