The remarkable story of the development of the extracorporeal support can be traced as far back as 1693, when Jean Baptiste Denis performed experiments cross-transfusing the blood of a human with the “gentle humors of a lamb” to determine if living blood could be transmitted between two species. Benjamin Ward Richardson MD, noted British Physician and anesthestist, conducted experiments in the 1860’s using injected oxygen and blood driven by a syringe to the right heart to generate artificial circulation in an animal model. Results were promising but limited by lack of anticoagulation. In the 1920’s Russian physician Sergei Brukhonenko and collaborator developed a total body perfusion system called the “autojector,” to perform successful experiments with isolation of the heart.

It was 1931, Dr. John Gibbon was in anguish over the loss of a young patient to a pulmonary embolism and wrote, “During that long night, helplessly watching the patient struggle for life as her blood became darker… the idea naturally occurred to me that if it were possible to remove continuously some of the blue blood… put oxygen into that blood… and then to inject continuously the now-red blood back into the patient’s arteries, we might have saved her life.” Collaborating with his wife Mary at Jefferson Medical School in Philadelphia, Dr. Gibbon developed a freestanding roller pump device for extracorporeal support. The initial Gibbon heart-lung machine was the size of a piano that created thin films of deoxygenated blood passing over a screen exposed to oxygen. 

On May 6, 1953, twenty-two years after his initial invention, he performed the first successful extracorporeally assisted repair of an atrial septal defect in 18 year-old Cecilia Bavolek. Dr. Lillehei further advanced extracorporeal circulation in the operating room in 1954 when he performed cardiac surgery via cross circulation and then progressed to using a bubble oxygenator he invented. Using this device past a few hours in the OR proved problematic due to the limited nature of availability of the device and hemolysis. Collaboration between biomedical engineers, physiologists, physicians, and surgeons began the next steps in development to create a device that could be used in the ICU without massive hemolysis and plasma leakage.

 Two inventions drove the next breakthrough; the invention of silicone in 1957 and the ability to allow prolonged circuit-blood exposure through controlled anticoagulation. The creation and use of silicone membranes for gas exchange was explored by Kolff and Dr. Kolobow and thus, the term “extracorporeal membrane oxygenator” came to be. Drs. Bartlett and Drinker recognized that the cardiac patient in the OR needed infinite anticoagulation due to stagnation in open repair, but with long-term circulating flow, less heparin would be required. They developed an approach to titrating coagulation and heparin dosing via the activated clotting time, which has remained in place for over 40 years.

In 1972, Barlett, Gazzaniga, and associates first successfully used cardiac ECMO for 36 hours in a 2-year old infant with cardiac failure following a mustard procedure for correction of transposition of the great vessels. ECMO support was extended outside of the operating room also in 1972 when Dr. J.D. Hill reported on the first successful cannulation and prolonged extra-corporeal circuit use in a patient in an intensive care setting. The patient was a 24-year old with a ruptured aorta and posttraumatic acute respiratory distress syndrome following a motorcycle accident, and who was supported with a membrane lung developed by Morrie Bramson. The patient received VA ECMO support for 75 hours, with subsequent decannulation and survival. 

Dr Robert Bartlett, who has been called the father of modern extra-corporeal support, made a therapeutic decision in 1975 that brought this technology to neonates with primary respiratory conditions. Faced with a newborn infant dying from meconium aspiration pneumonia and resultant pulmonary hypertension, Bartlett and colleagues brought an ECMO oxygenator to the NICU bedside from the laboratory, and sought consent from the infant’s mother. The mother signed consent and then disappeared, leaving her baby behind. The nursing staff named the child Esperanza, Spanish for “hope”. She received ECMO support for 72 hours, and then was decannulated with recovery, and a subsequent life with children of her own. 

Bartlett’s success and further experience helped drive growing successful expansion of use in neonates around the world. From 3 survivors among 16 patients treated by Bartlett and coworkers, clinical outcomes persistently improved, which promoted the interest and application in the surgical and intensive care community. Published reports showed ongoing improvements in outcomes, increasing survival rates 75% for neonatal diseases previously associated with only 10% survival. 

How incredible! In just 40 years, dynamic, ground-breaking advancements took place in the medical community by incredibly brave and creative people who didn’t settle, didn’t back down, and continued to push forward amidst so many challenges! May we continue to pursue and challenge the status quo with new innovations in an effort to help benefit advancements in medical therapy to help save lives. 

Overall outcomes of pediatric and adult ECMO are promising. The prevalence of ECLS use has increased dramatically as clinicians and medical centers increase their knowledge and awareness of the available therapy and management opportunity. 

References
Fortenberry, James D. “The History and Development of Extracorporeal Support.” Extracorporeal Life Support: The ELSO Red Book, edited by Roberto Lorusso, ELSO, 2017, pp. 1–29.