Bonde talks new surgery support systems

In late October, Connecticut saw its first hybrid extracoporeal membrane oxygenation-assisted surgery. This surgery burns away tissue that causes a dangerously rapid heart beat rhythm.
In late October, Connecticut saw its first hybrid extracoporeal membrane oxygenation-assisted surgery. This surgery burns away tissue that causes a dangerously rapid heart beat rhythm. Photo by Pramod Bonde.

In late October, Pramod Bonde, surgical director of the School of Medicine’s Mechanical Circulatory Support, and Joseph Akar, an electrophysiologist at the Yale School of Medicine, successfully performed a surgery on a patient with ventricular tachycardia, a life-threatening fast heart rhythm originating in one of the heart’s ventricles. This surgery, which burned the tissue causing the dangerously rapid heart rhythm, was Connecticut’s first hybrid extracorporeal membrane oxygenation-assisted (ECMO) procedure on a patient with VT. The ECMO system used by Bonde is characterized by the application of an artificial heart and lung support system, which facilitates such complex procedures. ECMO provides oxygen-rich blood and circulation support and can be utilized in patients with acute heart failure and acute respiratory failure both during surgery and during recovery. Over a year ago, Bonde started an adult ECMO service, also the first of its kind in Connecticut. Bonde’s ECMO program has seen impressive outcomes — in over a dozen patients needing support for acute respiratory failure, Bonde and his team have lost only one patient. The News spoke with Bonde in his office Monday morning.

Q: When did you first become interested and how did you first begin diving into this ECMO research?

A: I have a long-standing interest in the development and application of mechanical circulatory support. Most adult patients undergoing cardiac surgery are supported by an artificial heart and lung machine for an hour or two. However, some afflictions of the heart and lungs can take days to weeks and even months to heal. Early in my career, I thought to myself that, although we have a reliable way of doing heart surgery, we have no reliable way of supporting circulation and oxygenation of a man that can buy him some time until we figure out how we can fix his heart and lungs.

Q: The ECMO procedure is an established technique that surgeons use in hospitals throughout the country. How is your ECMO procedure distinct?

A: What I have done is streamlined the patient selection, procedural details, equipment set-up and post operation management to a simple “ten point” set of management goals. This allows everyone who is involved in caring for the patient — nurse, perfusionist, anesthesiologists, critical care attending, physician assistants, etc. — to have a very simplified target list within which the patient’s physiological parameters are maintained. Any deviation from these initiates an automatic action to correct this imbalance. This can only be achieved by all team members being on the same page and working towards a set of goals created for that particular patient. I think this is where the real innovation lies that directly results in improved survival and outcomes that we witnessed here at Yale.

Q: Could you describe some of your past experiences that have helped you develop procedures to accomplish these successes in surgery?

A: My artificial heart laboratory is focused on the development of the artificial heart and, recently, a bio-mimetic artificial lung that can work with normal room air. This type of work is crucial in allowing me to know which aspects to focus on in patient care and which are important. This tells me what is critical, what is the basic minimum thing you need to do, rather than looking at a hundred thousand things. You want to narrow it down to a critical component. The artificial heart and lung system that I am developing is important not just because of the development of the device, but how to implement it. The current ECMO device that is available is not portable. What I am trying to do is create an implantable, permanent device, which means an artificial lung and heart that can be put inside the patient’s body. Such a device will be accommodated within the patient’s own chest cavity in place of the diseased heart and lung. The clinically successful ECMO program helps to modify and understand what is clinically relevant and what is physically feasible to build in a lab.

Q: Is that the direction you’re headed in terms of extending this program?

A: Yes, our goal is to minimize the amount of things needed into a single portable unit. The device that I’m developing in the laboratory will be ideal for people who have end stage lung disease due to COPD [Chronic Obstructive Pulmonary Disease], who have pulmonary fibrosis, or who have cystic fibrosis. For those who are not candidates for lung transplantation, it will be a permanent artificial lung device. So it’s essential that this device will mimic the human lung that can be inserted into the chest and can last for months or years. We can’t keep someone in an ICU or a hospital for that long. We need to make sure they can go home to return to their families and friends and lead a productive life.

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