The next part, we will talk about the application of ECMO. We will talk about the VA ECMO for cardiac support, the VV ECMO for pulmonary support, and the ECPR, which means the ECMO assisted CPR. The feature of ECMO. The ECMO has a feature that is, easy set-up even during CPR situation. ECMO has dual support. The pump to support the heart, and the oxygenator to support the lung. Flexibility is also a feature of ECMO. We can use peripheral cannulation in ECMO. But if we use the central cannulation, then the ECMO will become a ventricular assisted device. There are current ECMO pumps in our hospital. The oldest type, the Medtronic old model, the Medtronic new models, [inaudible] and [inaudible] cardiac health system, and [inaudible] pump. All these pumps can work as ECMO in peripheral cannulation and sometimes we can use these machines to work as ventricular assisted device, if we use central cannulation. In cardiac support, for example, in pulmonary embolism. What is pulmonary embolism? The pulmonary embolism is the venous blood clot usually generated from the lower leg. The blood clot goes into the right heart through the venous system with the dark blood. The right heart pumps the blood clot into the pulmonary circulation, obstruct the pulmonary artery to occlude the pulmonary artery. The part of the lung which was occluded by the blood clot will not work as a normal lung where loss, the gas exchange, and the loss of the oxygenation functions. This is the physiology of pulmonary embolism. The outcomes in pulmonary embolism are very bad. It depends on the severity of the pulmonary embolism. The embolism size, and the cardiopulmonary status. If the patient with pulmonary embolism is in a shock status, then the mortality will up to 30 percent. If the patient already experienced a cardiac arrest, then the mortality will become 70 percent. The pathophysiology of pulmonary embolism. In the [inaudible]. When pulmonary embolism occurred, the pulmonary artery pressure will increase and increase the right ventricular after load. The right heart will [inaudible] and dysfunction, and decrease the output of the right heart. The pre-load of the left heart will decrease. The output of the heart will decrease. The systemic perfusion will decrease, and the patient will be in shatter status. If a patient suspects a massive pulmonary embolism and already has RV failure, shock. Or we treated the pulmonary embolism but failed. We will think about the ECMO to rescue the patient. The role of ECMO in pulmonary embolism. Because the pulmonary artery was obstructed by the black clot, we mentioned above. The black clot will interrupt between the left heart and the right heart. The blood of the right heart cannot pass through the pulmonary circulation, the lung, and go into the left heart. The oxygenation of the lung function was impaired by the blood clot. Therefore, no oxygenated blood flowing into the left heart. At this situation, we can set up the ECMO. The VA ECMO can bypass the blood from the heart and the lung through the femoral vein. After oxygenation in artificial lung, the ECMO can perfuse the red blood into the body through the femoral artery to give the patient oxygenation and give the patient perfusion. The concept of ECMO using the pulmonary embolism, in this literature the authors shows the picture in 30 years ago. This was 30 years old woman, experienced short periods of cardiac arrest, and after CPR research station, after chest pain. They used VA ECMO to support the patient. The patient did not intubate it, which means the patient no need to use the mechanical ventilation to support her respiration. Actually, the first idea of extra corporeal circulation was developed by Dr. John Gibbon in 1950s. The roles of ECMO in pulmonary embolism. ECMO can be life-saving measures in cases of circulatory collapse caused up by massive acute pulmonary embolism. The ECMO can keep the patients in stable conditions, and give enough time for diagnosis and treatment. The ECMO can also provide pulse operations support to support the heart and the lung. Here I showed the CT scan of pulmonary embolism. This part I indicate is the pulmonary artery. There is a fading defect in the left pulmonary artery, and in the right pulmonary artery there is also a fading effect. This is the blood clot. This also the blood clot in the pulmonary artery. The picture is a typical CT scan of pulmonary embolism, the fading defect in pulmonary arteries. How to treat pulmonary embolism. As a surgeon, we can use the surgical pulmonary embolism. This is the picture we did during the operation. This is the aortic cannula, this is the right aortic cannula. We set up the cardiopulmonary bypass, so we can empty the pulmonary artery and open the pulmonary artery here. Refreshing black blood clot, indicated here, this is the blood clot which is causing the pulmonary embolism in this patient. By this method, we can remove the blood clot under the director region, under surgeon's eye, and using the surgeon's hand to remove the blood clot to restore the circulation of pulmonary artery. We can do surgical pulmonary embolectomy under the cardio point bypass with aortic cross-clamp or without aortic cross-clamp. Which means, we can do the embolectomy under beating heart without cardioplegic arrest. This is the same patients. The Left pulmonary artery emboli after remove, we remove the whole part of the blood clot here. This is the same patients. After the operation, we remove all the blood clots in the right pulmonary artery, and in the left pulmonary artery. The patient can restore pulmonary circulation. The blood can pass through the lung and go back to the left heart.
