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        "titulo" => "<span class="elsevierStyleItalic">Extra-Corporeal Membrane Oxygenation</span> na insufici&#234;ncia respirat&#243;ria e circulat&#243;ria agudas&#58; uma terap&#234;utica cada vez mais &#224; m&#227;o"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Modalities of extracorporeal membrane oxygenation&#46; VA&#58; venoarterial&#44; for circulatory and&#47;or respiratory support&#59; VV&#58; venovenous&#44; for respiratory support&#46; Adapted from Squiers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation &#40;ECMO&#41; is being increasingly used for short-term circulatory and&#47;or respiratory support&#46; It is derived from extracorporeal circulation systems used in cardiac surgery in which blood is propelled by a centrifugal pump through an external membrane where gas exchange takes place&#46; The pump assists the heart and the membrane fulfills the functions of the lungs&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;2</span></a> ECMO is indicated in cases of respiratory failure such as acute respiratory distress syndrome&#44; or cardiac failure such as myocardial infarction complicated by cardiogenic shock&#44; which although acute carry the possibility of recovery&#44; and in patients with advanced chronic heart failure as a bridge to transplantation or decision&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#8211;5</span></a> Circulation is usually established via peripheral venous and&#47;or arterial cannulation&#44; increasingly by a percutaneous approach&#46; There are two basic types &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#58; veno-venous &#40;VV&#41;&#44; for respiratory support&#59; and venoarterial &#40;VV&#41;&#44; for circulatory and&#47;or cardiopulmonary support&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6&#44;7</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">ECMO is a highly effective and low-cost technique &#40;the console&#44; a one-off purchase&#44; costs around fifty thousand euros and the consumables around five thousand euros per patient&#41; that can be used in any hospital&#44; not necessarily tertiary&#46; Modern systems are portable and thus enable patients to be transferred between hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8&#8211;10</span></a> However&#44; although the system is relatively easy to use and to monitor even for those without a high degree of technical knowledge&#44; ECMO should only be performed by physicians who are trained and experienced in starting&#44; maintaining and ending the treatment&#44; and its use should be concentrated in specialist centers where a solid knowledge of respiratory and circulatory pathophysiology can render it most effective&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; the cardiology group at Vila Nova de Gaia describe their experience with 48 patients who underwent ECMO&#44; 26 of them VA-ECMO and 19 of them VV-ECMO&#44; over a period of around five and a half years&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> This is probably the largest series published in Portugal&#44; although larger ones have been published elsewhere&#46; The study&#39;s results are in agreement with those in high-volume centers with considerable experience&#46; Almost 70&#37; of patients in both groups were successfully weaned from ECMO and survival to hospital discharge was 37&#46;9&#37; in patients undergoing VA-ECMO and 63&#46;2&#37; in those receiving VV-ECMO&#46; Comparisons between these two groups is an interesting intellectual exercise but without real clinical significance&#44; given the differences between the two techniques and the patients treated&#44; in terms of both underlying disease and comorbidities&#46; As expected&#44; in the VA-ECMO group&#44; the need for more inotropic drugs&#44; an indication of greater myocardial dysfunction&#44; was a predictor of mortality&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Naturally&#44; a therapy of this kind is associated with not inconsiderable risks&#46; There is a high incidence of thromboembolism due to the large area of contact between the blood and the membrane and tubes making up the system&#44; and so at least some degree of anticoagulation is required&#44; which increases the likelihood of bleeding complications&#44; especially related to peripheral cannulation&#46; Anticoagulation and the traumatic effects of pumping on blood cells can give rise to serious hematological dysfunction&#44; including hemolysis and thrombocytopenia&#46; There is also a risk of local and systemic infection&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Furthermore&#44; blood circulation in ECMO is not physiologically pulsatile&#44; especially in cases of severe myocardial dysfunction in which there is little or no ejection by the heart&#46; This can result in inadequate perfusion of vital organs such as the brain&#44; kidneys&#44; liver and gastrointestinal tract&#44; particularly if the therapy is prolonged&#46; Finally&#44; the cannulated peripheral vessels are prone to vascular complications&#44; including ischemia of downstream territories&#46; This is a common complication when the femoral artery is cannulated&#44; and so a shunt is now routinely placed to maintain distal perfusion&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Besides the course of the underlying disease&#44; these complications are themselves frequently a cause of death&#44; thus seriously compromising medium- and long-term survival&#46; Notwithstanding&#44; it should be borne in mind that these patients would very likely not survive without such treatment&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Unfortunately&#44; of the nine patients in the Gaia group&#39;s series who were referred for cardiac transplantation &#40;one of the indications for ECMO&#41;&#44; only three were transplanted and of these only one survived&#44; the rest dying while awaiting a donor&#46; The length of waiting lists and the time spent on them are due to the lack of donors&#46; Although patients receiving mechanical ventricular assistance are always given top priority&#44; and although the laws governing organ donation in Portugal are among the most liberal in the world &#40;our donation rates are among the highest in Europe&#44; around 30 donors per million population&#41;&#44; often the new heart does not arrive in time&#46; In my center&#44; survival in transplanted patients with a ventricular assist device was around 70&#37;&#44; but mortality in those on ventricular assistance for more than two weeks at the time of transplantation was much higher than in those who were transplanted earlier&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; ECMO is being used as a ventricular assist technique in several centers in Portugal&#44; particularly those with on-site cardiac surgery facilities&#44; which is to be expected given the specific applications of the technology&#46; However&#44; in principle it should be available for all patients in all the hospitals in the country&#44; since the equipment is portable and so patients and supporting teams can move without undue risk from peripheral centers to tertiary hospitals&#46; This occurred with many of the patients treated at the Gaia center&#44; where almost half of patients undergoing VA-ECMO were transferred in cardiogenic shock from another hospital&#44; but experience suggests that these patients might benefit from having the device placed in the hospital of origin&#44; before being transferred&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> With growing experience and ever-improving results&#44; the indications for this therapeutic modality are continuing to widen&#46; Nevertheless&#44; it is essential to avoid using ECMO in patients in whom it would be futile &#8211; those in the terminal stages of disease&#44; those treated for too long by conventional means&#44; and those diagnosed with a fatal condition&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Extracorporeal membrane oxygenation in acute respiratory and cardiac failure: An increasingly accessible therapy
Extra-Corporeal Membrane Oxygenation na insuficiência respiratória e circulatória agudas: uma terapêutica cada vez mais à mão
Manuel J. Antunes
Centro de Cirurgia Cardiotorácica, Hospital da Universidade e Faculdade de Medicina, Coimbra, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation &#40;ECMO&#41; is being increasingly used for short-term circulatory and&#47;or respiratory support&#46; It is derived from extracorporeal circulation systems used in cardiac surgery in which blood is propelled by a centrifugal pump through an external membrane where gas exchange takes place&#46; The pump assists the heart and the membrane fulfills the functions of the lungs&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1&#44;2</span></a> ECMO is indicated in cases of respiratory failure such as acute respiratory distress syndrome&#44; or cardiac failure such as myocardial infarction complicated by cardiogenic shock&#44; which although acute carry the possibility of recovery&#44; and in patients with advanced chronic heart failure as a bridge to transplantation or decision&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#8211;5</span></a> Circulation is usually established via peripheral venous and&#47;or arterial cannulation&#44; increasingly by a percutaneous approach&#46; There are two basic types &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#58; veno-venous &#40;VV&#41;&#44; for respiratory support&#59; and venoarterial &#40;VV&#41;&#44; for circulatory and&#47;or cardiopulmonary support&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6&#44;7</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">ECMO is a highly effective and low-cost technique &#40;the console&#44; a one-off purchase&#44; costs around fifty thousand euros and the consumables around five thousand euros per patient&#41; that can be used in any hospital&#44; not necessarily tertiary&#46; Modern systems are portable and thus enable patients to be transferred between hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8&#8211;10</span></a> However&#44; although the system is relatively easy to use and to monitor even for those without a high degree of technical knowledge&#44; ECMO should only be performed by physicians who are trained and experienced in starting&#44; maintaining and ending the treatment&#44; and its use should be concentrated in specialist centers where a solid knowledge of respiratory and circulatory pathophysiology can render it most effective&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; the cardiology group at Vila Nova de Gaia describe their experience with 48 patients who underwent ECMO&#44; 26 of them VA-ECMO and 19 of them VV-ECMO&#44; over a period of around five and a half years&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> This is probably the largest series published in Portugal&#44; although larger ones have been published elsewhere&#46; The study&#39;s results are in agreement with those in high-volume centers with considerable experience&#46; Almost 70&#37; of patients in both groups were successfully weaned from ECMO and survival to hospital discharge was 37&#46;9&#37; in patients undergoing VA-ECMO and 63&#46;2&#37; in those receiving VV-ECMO&#46; Comparisons between these two groups is an interesting intellectual exercise but without real clinical significance&#44; given the differences between the two techniques and the patients treated&#44; in terms of both underlying disease and comorbidities&#46; As expected&#44; in the VA-ECMO group&#44; the need for more inotropic drugs&#44; an indication of greater myocardial dysfunction&#44; was a predictor of mortality&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Naturally&#44; a therapy of this kind is associated with not inconsiderable risks&#46; There is a high incidence of thromboembolism due to the large area of contact between the blood and the membrane and tubes making up the system&#44; and so at least some degree of anticoagulation is required&#44; which increases the likelihood of bleeding complications&#44; especially related to peripheral cannulation&#46; Anticoagulation and the traumatic effects of pumping on blood cells can give rise to serious hematological dysfunction&#44; including hemolysis and thrombocytopenia&#46; There is also a risk of local and systemic infection&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Furthermore&#44; blood circulation in ECMO is not physiologically pulsatile&#44; especially in cases of severe myocardial dysfunction in which there is little or no ejection by the heart&#46; This can result in inadequate perfusion of vital organs such as the brain&#44; kidneys&#44; liver and gastrointestinal tract&#44; particularly if the therapy is prolonged&#46; Finally&#44; the cannulated peripheral vessels are prone to vascular complications&#44; including ischemia of downstream territories&#46; This is a common complication when the femoral artery is cannulated&#44; and so a shunt is now routinely placed to maintain distal perfusion&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Besides the course of the underlying disease&#44; these complications are themselves frequently a cause of death&#44; thus seriously compromising medium- and long-term survival&#46; Notwithstanding&#44; it should be borne in mind that these patients would very likely not survive without such treatment&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Unfortunately&#44; of the nine patients in the Gaia group&#39;s series who were referred for cardiac transplantation &#40;one of the indications for ECMO&#41;&#44; only three were transplanted and of these only one survived&#44; the rest dying while awaiting a donor&#46; The length of waiting lists and the time spent on them are due to the lack of donors&#46; Although patients receiving mechanical ventricular assistance are always given top priority&#44; and although the laws governing organ donation in Portugal are among the most liberal in the world &#40;our donation rates are among the highest in Europe&#44; around 30 donors per million population&#41;&#44; often the new heart does not arrive in time&#46; In my center&#44; survival in transplanted patients with a ventricular assist device was around 70&#37;&#44; but mortality in those on ventricular assistance for more than two weeks at the time of transplantation was much higher than in those who were transplanted earlier&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; ECMO is being used as a ventricular assist technique in several centers in Portugal&#44; particularly those with on-site cardiac surgery facilities&#44; which is to be expected given the specific applications of the technology&#46; However&#44; in principle it should be available for all patients in all the hospitals in the country&#44; since the equipment is portable and so patients and supporting teams can move without undue risk from peripheral centers to tertiary hospitals&#46; This occurred with many of the patients treated at the Gaia center&#44; where almost half of patients undergoing VA-ECMO were transferred in cardiogenic shock from another hospital&#44; but experience suggests that these patients might benefit from having the device placed in the hospital of origin&#44; before being transferred&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> With growing experience and ever-improving results&#44; the indications for this therapeutic modality are continuing to widen&#46; Nevertheless&#44; it is essential to avoid using ECMO in patients in whom it would be futile &#8211; those in the terminal stages of disease&#44; those treated for too long by conventional means&#44; and those diagnosed with a fatal condition&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Antunes MJ&#46; <span class="elsevierStyleItalic">Extra-Corporeal Membrane Oxygenation</span> na insufici&#234;ncia respirat&#243;ria e circulat&#243;ria agudas&#58; uma terap&#234;utica cada vez mais &#224; m&#227;o&#46; Rev Port Cardiol&#46; 2017&#59;36&#58;843&#8211;845&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Modalities of extracorporeal membrane oxygenation&#46; VA&#58; venoarterial&#44; for circulatory and&#47;or respiratory support&#59; VV&#58; venovenous&#44; for respiratory support&#46; Adapted from Squiers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p>"
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Revista Portuguesa de Cardiologia (English edition)
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