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You can never be too prepared: ECMO for MCA

Published:September 19, 2018DOI:https://doi.org/10.1016/j.ajog.2018.09.019
      To the Editors:
      We have read with great interest the clinical review by Zelop et al.
      • Zelop C.M.
      • Einav S.
      • Mhyre J.M.
      • Martin S.
      Cardiac arrest during pregnancy: ongoing clinical conundrum—an expert review.
      These topics were very informative and important for many clinicians. From the perspective of the cardiologist, we have commented on the extracorporeal membrane oxygenation (ECMO) strategy.
      As Zelop et al
      • Zelop C.M.
      • Einav S.
      • Mhyre J.M.
      • Martin S.
      Cardiac arrest during pregnancy: ongoing clinical conundrum—an expert review.
      mentioned, even if exceeding 4 minutes after collapsed, perimortem cesarean delivery (PMCD) should be considered for maternal cardiac arrest (MCA). At the same time, we recommend that physicians consider the enactment of ECMO as soon as possible. Recent American Heart Association guidelines admitted ECMO as one of the options for cardiopulmonary resuscitation (CPR), called extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation (ECPR). ECPR is usually suggested after conventional CPR has been performed for more than 10 minutes. Considering the fact that the time to establish the system of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is 10–20 minutes, we should consider ECMO and PMCD decisions for out-of-hospital MCA patients as early as possible.
      Obviously although many MCA cases occur in hospital settings and one fourth of those cases were related to anesthetic problems, we should select ECMO candidates promptly. For example, 18.6% of MCA cases (11 of 59) were due to venous and thromboembolic causes according to the Cardiac Arrhythmia Pilot Study (CAPS) trial, and unfortunately, many of them died (10 of 11, 90.9%).
      • Beckett V.
      • Knight M.
      • Sharpe P.
      The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study.
      In Japan, a national survey revealed that about 6% of MCA cases were related to a pulmonary embolism. Furthermore, a CHEER trial about ECPR for pulmonary embolisms revealed early ECPR implementation might be beneficial.
      • Stub D.
      • Bernard S.
      • Pellegrino V.
      • et al.
      Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).
      Therefore, we should not ignore a potential candidate for ECMO, such as a patient with a pulmonary embolism and avoid delaying the implementation of ECPR for one such candidate. Goto et al
      • Goto M.
      • Watanabe H.
      • Ogita K.
      • Matsuoka T.
      Perimortem cesarean delivery and subsequent emergency hysterectomy: new strategy for maternal cardiac arrest.
      developed a relatively new algorithm to initiate VA-ECMO by an emergent physician at the same time as the decision to enact a PMCD, which might be reasonable for many MCAs.
      We admit that evidence was scarce, but combining the results from previous ECMO studies and studies about MCA has led us to recommend earlier consideration of ECMO therapy. As mentioned by Zelop et al,
      • Zelop C.M.
      • Einav S.
      • Mhyre J.M.
      • Martin S.
      Cardiac arrest during pregnancy: ongoing clinical conundrum—an expert review.
      incorporating multidisciplinary teams, including an emergent physician, obstetrician/maternal-fetal medicine specialist, anesthesiologist, and cardiologist to diagnose an appropriate candidate for ECMO, is mandatory for MCA to perform time-efficient treatment.

      References

        • Zelop C.M.
        • Einav S.
        • Mhyre J.M.
        • Martin S.
        Cardiac arrest during pregnancy: ongoing clinical conundrum—an expert review.
        Am J Obstet Gynecol. 2018; 219: 52-61
        • Beckett V.
        • Knight M.
        • Sharpe P.
        The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study.
        BJOG. 2017; 124: 1374-1381
        • Stub D.
        • Bernard S.
        • Pellegrino V.
        • et al.
        Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).
        Resuscitation. 2015; 86: 88-94
        • Goto M.
        • Watanabe H.
        • Ogita K.
        • Matsuoka T.
        Perimortem cesarean delivery and subsequent emergency hysterectomy: new strategy for maternal cardiac arrest.
        Acute Med Surg. 2017; 4: 467-471

      Linked Article

      • Cardiac arrest during pregnancy: ongoing clinical conundrum
        American Journal of Obstetrics & GynecologyVol. 219Issue 1
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          While global maternal mortality has decreased in the last 25 years, the maternal mortality ratio in the United States has actually increased. Maternal mortality is a complex phenomenon involving multifaceted socioeconomic and clinical parameters including inequalities in access to health care, racial and ethnic disparities, maternal comorbidities, and epidemiologic ascertainment bias. Escalating maternal mortality underscores the importance of clinician preparedness to respond to maternal cardiac arrest that may occur in any maternal health care setting.
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        American Journal of Obstetrics & GynecologyVol. 220Issue 1
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          We thank Mizuno et al for their interest in our review and acknowledge their astute commentary. As detailed in our review,1 we have explored extracorporeal membrane oxygenation (ECMO) and cardiopulmonary bypass as additional interventions that may provide external hemodynamic and/or respiratory support when the etiology of maternal cardiac arrest is potentially reversible. Clinical entities that may be amenable include local anesthetic toxicities unresponsive to lipid rescue, drug overdose, respiratory failure, acute respiratory distress syndrome, cardiomyopathy, and pulmonary/amniotic fluid embolism.
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