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Published:September 19, 2018DOI:https://doi.org/10.1016/j.ajog.2018.09.021
      We thank Mizuno et al for their interest in our review and acknowledge their astute commentary. As detailed in our review,
      • Zelop C.M.
      • Einav S.
      • Mhyre J.M.
      • Martin S.
      Cardiac arrest during pregnancy: ongoing clinical conundrum: an expert review.
      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.
      While the American Heart Association incorporated extracorporeal membrane oxygenation resuscitation as an alternative intervention in the 2015 guidelines,

      American Heart Association. 2015 guidelines for cardiopulmonary resuscitation. Executive summary. Part 6. Alternative techniques and ancillary devices for CPR. Available at: https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/executive-summaries/part-1-executive-summary/. Accessed Sept. 4, 2018.

      data are limited, especially in the setting of pregnancy. Barriers to implementation of this intervention revolve around pathophysiology and feasibility.
      The prothrombotic maternal coagulation system is highly complex, especially when amniotic or pulmonary embolism is superimposed. With either of these clinical entities, the interactions between heart strain and perfusion pressures, anticoagulation, disseminated intravascular coagulation, hypothermic cooling, ECMO, and the presence of a surgical wound lead to an intricate interplay of risks that may culminate in exsanguination, irreversible cardiac failure, permanent brain damage, multiorgan injury, and maternal and perinatal death.
      • Biderman P.
      • Carmi U.
      • Setton E.
      • Fainblut M.
      • Bachar O.
      • Einav S.
      Maternal salvage with extracorporeal life support: lessons learned in a single center.
      ECMO resources require time to deploy, and therefore, it is reasonable to incorporate cardiology and cardiothoracic surgery into the multidisciplinary team managing maternal cardiac arrest. Consideration of implementation of this modality should not compromise the initial maneuvers of resuscitation including perimortem delivery. Simulation exercises will facilitate the education of clinical providers to prioritize time-sensitive interventions and enhance teamwork.
      While no modality should be dismissed as a possible maternal life-saving intervention, ECMO and cardiopulmonary bypass do present extraordinary circumstances and clinical challenges. The need for national and international registries is truly urgent.

      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
      1. American Heart Association. 2015 guidelines for cardiopulmonary resuscitation. Executive summary. Part 6. Alternative techniques and ancillary devices for CPR. Available at: https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/executive-summaries/part-1-executive-summary/. Accessed Sept. 4, 2018.

        • Biderman P.
        • Carmi U.
        • Setton E.
        • Fainblut M.
        • Bachar O.
        • Einav S.
        Maternal salvage with extracorporeal life support: lessons learned in a single center.
        Anesth Analg. 2017; 125: 1275-1280

      Linked Article

      • You can never be too prepared: ECMO for MCA
        American Journal of Obstetrics & GynecologyVol. 220Issue 1
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          We have read with great interest the clinical review by Zelop et al.1 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.
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