The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation

Abstract

Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the “Father of ECMO”—Dr. Robert Bartlett, describe the history and advances of ECMO.

21st century critical care medicine: An overview

“…ECMO technology was developed in the 1960s and used on humans for the first time in the 1970s[ 62 , 63 ]. Due to the advancement of technology, new extracorporeal circuit design, and better ventilation strategies, observational studies started reporting promising results in terms of survival outcomes[ 64 , 65 ].…”

Detecting Oxygenator Thrombosis in ECMO: A Review of Current Techniques and an Exploration of Future Directions

“…However, the optimal anticoagulation protocol to minimize the risk of bleeding and thrombotic events in ECMO (as determined by ACT, aPTT, anti-Xa, and VHAs) remains a subject of ongoing research, with limited consensus currently established. 14,52,59 As normal hemostasis is difficult to achieve in ECMO, it is paramount that there are techniques for detecting both the degree of clotting and bleeding within the patient and the circuit.…”

“…12 Despite these distinctions, both adult and pediatric ECMO share the challenge of contact with artificial surfaces and turbulent flow leading to clot formation. To reduce the need for systemic anticoagulation, ECMO components are commonly manufactured with antithrombotic surface coatings, 13 14 although the perfect biomaterial has not yet been discovered. Additionally, circuit thrombosis incidence rates can be increased by prothrombotic conditions such as infection and hemolysis.…”

Rates, Outcomes, and Resource Burden of Extracorporeal Membrane Oxygenation Use in Hospitalizations in the United States During the Pandemic

“…Hill et al reported the first-time use of ECMO for respiratory support in an adult patient with post-traumatic severe respiratory failure. Bartlett et al went on to successfully use ECMO for neonates experiencing severe respiratory distress in 1975 [ 5 , 6 ]. Initially developed as a modification of cardiopulmonary bypass techniques used in open-heart surgery, ECMO evolved to support patients with severe respiratory or cardiac failure.…”