Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, our discussion focuses on an update of the Adult ECMO Program at UAB Medicine. Joining me is Dr. Keith Wille. He's the Medical Director of the Adult ECMO and Advanced Lung Diseases Program at UAB Medicine.

Dr. Wille, it's such a pleasure to have you join us again today. And since we're updating this topic and we've done a previous podcast on it, what's different? Are there any exciting updates to share? Tell us what's going on with the Adult ECMO Program at uAB Medicine.

Keith Wille, MD: So, thank you for having me today, Melanie. It's very exciting to be here and to share some of the happenings with the ECMO Program with the audience. There are several exciting initiatives that I think are happening with us. Those are happening both internally within our program as well as somewhat externally around the state.

So, first off, I think internally we're trying to expand services as best as possible to help support patients that are in need or might benefit from ECMO support. And those are typically patients with severe forms of respiratory failure or cardiac or heart failure.

And the other exciting part of this has been trying to expand our services throughout the state, really to be a referral source, and to provide assistance throughout the state for patients that can either come here or ultimately be transported here. And we're partnering with our critical care transport service as well as several outside hospitals to try to make that happen and help patients as best as we can throughout the state.

Melanie Cole, MS: Well, thank you for that, Dr. Wille. So, what is some of the most significant advancements in our understanding of the uses for ECMO since you began practicing medicine? Because as I understand it, it's being more used for different situations than it used to be.

Keith Wille, MD: I think that's true. So in general, when we think about deploying ECMO for patients, we're really trying to identify what the goal of this therapy is to start with. And so, the three principle goals would be to use this device as a bridge to recovery, whether it be heart failure or respiratory failure.

The other goal that we use is bridge to some kind of transplant. Heart or lung transplant would be the more common endpoints for that. But for heart failure, we also have options for mechanical circulatory support as a potential endpoint as well. And then the last is, and probably the least frequent, is what we call a bridge to decision. And it's, I think, when someone unfortunately gets acutely sick and it's not quite clear they have candidacy for transplantation, and it's really not quite well known whether they have capacity to recover from illness. But the teams and the patient and the patient's family just need some time to sort out what the outcome possibilities are and whether ECMO might be utilized to bridge a patient to that particular outcome.

Melanie Cole, MS: Well, thank you for explaining those three reasons for deploying ECMO. Really, that was very comprehensive and informational. So, thank you for that. Now, as we think about those primary indications and how far ECMO has come over the years, tell us a little bit about the technology in ECMO that's changed that's been pretty exciting.

Keith Wille, MD: So, the principle mechanism by which we support patients with ECMO really hasn't changed substantially in terms of that the device is still driven by a pump. It utilizes a gas exchange membrane to send oxygen back to the patient and eliminate carbon dioxide. And then, we use cannulas to essentially provide the circulatory support for those patients, the drainage and return of blood to the patients. And then, whether or not patients get cardiac or heart support largely depends on how these cannulas are deployed and specifically whether they are placed in a vein and an artery or two veins.

There have been some changes in the technology in terms of the cannulas that we use and deploy. Devices have largely become more portable to allow for patients to walk while on ECMO support. So, physical therapy has become a really integral part of caring for patients that are on ECMO. And I think those are the principle changes that we've seen over the last several years.

So, we've always had the capacity for mobility and participation in physical therapy while on ECMO support. However, I think the changes in cannulation strategies, the equipment itself, and our protocols for managing patients have facilitated easier abilities to participate in physical therapy. And physical therapy is very, very critical for these patients, as we know in all aspects of ICU care. We see it in this arena as well where participating in physical therapy and staying strong is just an important aspect to recovering from these kinds of illnesses.

Melanie Cole, MS: How interesting. And that's a pretty exciting change to be able to include adjuvant therapies that really can help the patient to improve. And Dr. Wille, beyond the technical aspects, I'd like you to speak about the multidisciplinary team's role and responsibility in managing these patients on whether long-term or short-term ECMO support for respiratory or cardiac. How do you ensure that coordinated care and communication among your team members?

Keith Wille, MD: So, we are fortunate in that we have a true multidisciplinary team comprised of our cardiovascular surgical group, and as well as our critical care intensivist physicians. And as often as possible, we try to round and see patients simultaneously so that there can be a good discussion about the goals of care for the day.

In addition to the physicians, we have a very good group of advanced practitioners that have added experience in ECMO care. We have perfusionists at the bedside and we have nurses called nurse ECMO specialists who've had advanced training in the management and care of patients with ECMO. In addition to that, we have physical therapists, nutritionists, and other key personnel who comprised the team and really help in the multidisciplinary aspects of the care for these patients. So, it's really a team effort.

Melanie Cole, MS: Well, I would think that it would have to be. And what an exciting time in your field to be able to look at this technology and do what you do. And when we think of long-term ECMO and that kind of support, that can significantly impact a patient's quality of life and prognosis, I'd like you to speak as we get ready to wrap up some of the key considerations that you use, Dr. Wille, when deciding to initiate ECMO as a bridge to recovery or transplantation, or decision-making, as you said, but that's more rare versus as a destination therapy. And what are you looking at for the patient? How do you work with the patient and their families with that shared decision-making?

Keith Wille, MD: When we're thinking of deploying ECMO support, probably the most common potential contraindication that come up relate to the timing of patients that have been on mechanical ventilatory support. And in general, we look for patients to be on mechanical ventilation for approximately seven days or less, and there's some literature to support that decision.

The other aspect that sometimes comes up from a referring practice is bleeding episodes. And while we have been able to support patients with less anticoagulation and in some circumstances with no anticoagulation, it's really an individual assessment, but we are always as a program happy to talk to any referring physicians that may have patients under consideration. And the mechanical ventilatory support duration was principally directed toward those patients that might have ARDS or acute respiratory failure. For patients that have cardiac or heart failure, usually, the need to deploy ECMO is faster than a several day period. So, it's a pretty quick decision as to whether or not those patients might be candidates.

Melanie Cole, MS: Do you have any final thoughts, Dr. Wille, for other providers, what you would like the key takeaways to be on the Adult ECMO Program at UAB Medicine?

Keith Wille, MD: I think the key takeaways are, number one, our ECMO program exists and we are here to try to serve our communities as best as possible. I think we are always happy to discuss potential candidates for ECMO with any referring provider and can be contacted through the MIST operator.

And I think the principal goals again relate largely to what we're trying to accomplish with our ECMO support. Is this a patient that has a capacity to recover and get back to a previous quality of life, or is this a patient where some kind of bridging to either transplantation or device therapy needs to be considered?

Melanie Cole, MS: Thank you so much, Dr. Wille, for joining us. And you're such a great expert in this field and a great guest. Thank you so much again. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.