MedStar Washington Hospital Center

Akram M. Zaaqoq

Dr. Akram M. Zaaqoq is a cardiac critical care physician and scientist. He is board-certified in critical care medicine by the American Board of Internal Medicine (ABIM) with a decade of clinical experience. He finished his critical care medicine and research fellowship at the University of Pittsburgh Medical Center (UPMC), where he still holds an adjunct research position in the department of surgery. The primary clinical focus is on managing critically ill patients and complex medical cases that require life-saving supportive measures, mainly acute mechanical support devices.

Currently, Dr. Zaaqoq serves as an assistant professor of clinical medicine at Georgetown University and also as a Medical Director for the Extracorporeal membrane oxygenation (ECMO) program at MedStar Washington Hospital Center.

In an interview with Healthcare Tech Outlook Magazine, Dr. Akram M. Zaaqoq explains how Extracorporeal Membrane Oxygenation is changing the critical care paradigm by bringing new opportunities to healthcare.

What are some of the most significant problems and advantages that ECMO has brought to critical care?

Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, brings with it a plethora of opportunities while also posing numerous challenges.

Beginning with the benefits that ECMO has brought to the medical field, it ensures adequate but temporary substitute of the heart or lung function to patients suffering from reversible cardiac and/or respiratory failure. It helps in stabilizing the patient and sustains life till the time the heart and lungs recover. For example, it works after complex heart and lung surgeries, massive clots to the lungs, some cases of a drug overdose, trauma to the heart or the lung, and even in particular cases when the heart stops completely. In the case of irreversible diseases, it can serve as a bridge to permanent device therapy such as left ventricular assist device or transplantation.

The major hindrance in the development of the ECMO program is the cost factor. ECMO treatment is expensive due to the high cost of the machines and disposables, higher recurring or maintenance charges per day, extended length of the intensive care unit (ICU) stay, need for other supportive therapies, and involvement of several highly trained professionals. As a sophisticated tool, it necessitates extensive training and exceptional experience in managing patients on an ECMO program. Hence it is usually available in large institutions, such as MedStar Washington Hospital Center, where they have this experience.

Another significant problem is the decision to discontinue life support (ECMO) in the event of a lack of response to extended ECMO because the longer patients are on ECMO, the greater the risk of complications and potential suffering. This leads to an ethical challenge that care providers and family members confront in terms of making difficult decisions regarding their loved one's future actions.

"We attempt to keep as many patients alive as possible while they are in recovery or awaiting transplant, as well as give them greater independence and a higher quality of life."

What was the impact of Covid-19 on ECMO programs, and how did you overcome it?

The pneumonia associated with novel coronavirus disease leads to respiratory failure with profound hypoxemia requiring endotracheal intubation and mechanical ventilation. When doctors around the world were looking for effective ways to treat and save the lives of COVID-19 patients, one treatment option that showed promise was the use of ECMO. By supporting the heart and lungs, the ECMO machine stabilizes patients to allow their bodies more time to fight the virus. As a program designated as a Center on Path to Excellence in Life Support by the Extracorporeal Life Support Organization (ELSO), the ECMO team is uniquely experienced and positioned to help COVID-19 patients.

However, the biggest challenge during this time was dealing with limited resources and inexperienced staff. It was difficult to establish programs and train staff to give them the confidence to manage patients in such a short period of time. To overcome this barrier, the concept of regional coordination between various institutions was proposed. This allows us to regionalize patients from smaller institutions and refer them to ECMO centers that can help to provide appropriate treatment from experienced experts.

Furthermore, to overcome an ethical dilemma, which is one of the most difficult challenges of ECMO, we have begun to implement a step-by-step approach to educate the family and ensure adequate communication. So, suppose the situation calls for a difficult decision, the family will be prepared to make the best decision for their beloved ones.

How do you anticipate the future of ECMO?

ECMO technology is rapidly improving. The devices are becoming more compatible with blood and the human body, indicating that the patient will encounter fewer difficulties while on ECMO than before. Portable ECMO devices that will be available in the near future will essentially assist patients in traveling and make it less risky. Furthermore, we seek to develop portable ECMO devices for chronic diseases such as chronic obstructive pulmonary disease or patients with severe asthma. We attempt to keep as many patients alive as possible while they are waiting for a transplant, as well as giving them greater independence and a higher quality of life.

 Is there any advice you'd that you want to share with your colleagues in this space?

The most important advice is that if they have a patient who could benefit from ECMO, they should start as soon as possible. If ECMO capabilities are not available in that specific institution, it can be done by collaborating with hospitals specializing in that seat. It is better if these patients are referred to hospitals early on to achieve the best possible outcome. Furthermore, for those attempting to establish ECMO programs, collaborating with professional societies such as ELSO can help with providing training to the staff, as this would be the most effective way to assist patients.