Letteratura scientifica selezionata sul tema "Peripheral veno-arterial ECMO"

Background: It is unclear whether peripheral arterial cannulation is superior to central arterial cannulation for postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Methods: A systematic review was conducted using PubMed, Scopus, and Google Scholar to identify studies on postcardiotomy VA-ECMO for the present individual patient data (IPD) meta-analysis. Analysis was performed according to the intention-to-treat principle. Results: The investigators of 10 studies agreed to participate in the present IPD meta-analysis. Overall, 1269 patients were included in the analysis. Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA-ECMO were 70.7% vs. 63.7%, respectively (adjusted OR 1.38, 95% CI 1.08–1.75). Propensity score matching yielded 538 pairs of patients with balanced baseline characteristics and operative variables. Among these matched cohorts, central arterial cannulation VA-ECMO was associated with significantly higher in-hospital mortality compared to peripheral arterial cannulation VA-ECMO (64.5% vs. 70.8%, p = 0.027). These findings were confirmed by aggregate data meta-analysis, which showed that central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation (OR 1.35, 95% CI 1.04–1.76, I2 21%). Conclusions: Among patients requiring postcardiotomy VA-ECMO, central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation. This increased risk is of limited magnitude, and further studies are needed to confirm the present findings and to identify the mechanisms underlying the potential beneficial effects of peripheral VA-ECMO.

Cardiogenic shock and cardiac arrest are life-threatening emergencies that result in high mortality rates. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) via peripheral cannulation is an option for patients who do not respond to conventional therapies. Left ventricular (LV) distention is a major limitation with peripheral VA-ECMO and is thought to contribute to poor recovery and the inability to wean off VA-ECMO. We report on a novel technique that combines peripheral VA-ECMO with off-pump insertion of a trans-apical LV venting cannula and a right ventricular decompression cannula.

Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting. Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation. Results: A total of 32 patients (age 53 (interquartiles, IQRs: 31–59) years) were identified: 16 were initially supported with VA-ECMO and 16 with VV-ECMO. The median time to V-AV conversion was 2 (1–5) days. After V-AV implantation, heart rate and norepinephrine dose significantly decreased, while PaO2 and SaO2 significantly increased compared to baseline values. Lactate levels significantly decreased from 3.9 (2.3–7.1) to 2.8 (1.4–4.4) mmol/L (p = 0.048). A significant increase in the overall ECMO blood flow (from 4.5 (3.8–5.0) to 4.9 (4.3–5.9) L/min; p < 0.01) was observed, with 3.0 (2.5–3.2) L/min for the arterial and 2.8 (2.1–3.6) L/min for the venous return flows. Conclusions: In ECMO patients with differential hypoxia or persistently low cardiac output syndrome, V-AV conversion was associated with improvement in some hemodynamic and respiratory parameters. A significant increase in the overall ECMO blood flow was also observed, with similar flow distributed into the arterial and venous return cannulas.

Background: The present study aimed to assess the determinants of arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2) in the early phase of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Even though the guidelines considered both the risks of hypoxemia and hyperoxemia during ECMO support, there are a lack of data concerning the patients supported by VA ECMO. Methods: This is a retrospective, monocentric, observational cohort study in a university-affiliated cardiac intensive care unit. Hemodynamic parameters, ECMO parameters, ventilator settings, and blood gas analyses were collected at several time points during the first 48 h of VA ECMO support. For each timepoint, the blood samples were drawn simultaneously from the right radial artery catheter, VA ECMO venous line (before the oxygenator), and from VA ECMO arterial line (after the oxygenator). Univariate followed by multivariate mixed-model analyses were performed for longitudinal data analyses. Results: Forty-five patients with femoro-femoral peripheral VA ECMO were included. In multivariate analysis, the patients’ PaO2 was independently associated with QEC, FDO2, and time of measurement. The patients’ PaCO2 was associated with the sweep rate flow and the PpreCO2. Conclusions: During acute VA ECMO support, the main determinants of patient oxygenation are determined by VA ECMO parameters.

Differential hypoxia and the arterial mixing zone are two important factors in managing peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). With the aim of improving perfusion to the aortic arch branches and coronaries, we describe our approach for VA-ECMO cannulation: bicaval drainage through the femoral vein and proximal retrograde ECMO flow using a multi-stage venous cannula inserted in the femoral artery and the tip placed at the proximal descending thoracic aorta. We report the use of this VA-ECMO approach on a 15-year-old female with combined cardiorespiratory failure and on a 12-year-old male with acute cardiac failure.

Extracorporeal membrane oxygenation (ECMO) is a vital emergency procedure providing respiratory and circulatory support to critically ill patients, especially those with compromised cardiopulmonary function. Its use has grown due to technological advances and clinical demand. Prolonged ECMO usage can lead to complications, necessitating the timely assessment of peripheral microcirculation for an accurate physiological evaluation. This study utilizes non-invasive near-infrared spectroscopy (NIRS) to monitor knee-level microcirculation in ECMO patients. After processing oxygenation data, machine learning distinguishes high and low disease severity in the veno-venous (VV-ECMO) and veno-arterial (VA-ECMO) groups, with two clinical parameters enhancing the model performance. Both ECMO modes show promise in the clinical severity diagnosis. The research further explores statistical correlations between the oxygenation data and disease severity in diverse physiological conditions, revealing moderate correlations with the acute physiologic and chronic health evaluation (APACHE II) scores in the VV-ECMO and VA-ECMO groups. NIRS holds the potential for assessing patient condition improvements.

Background and objectives: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) cannulas have major repercussions on vascular hemodynamics that can potentially lead to limb ischemia. Duplex ultrasound enables the non-invasive analysis of vascular hemodynamics. This study aims to describe the duplex parameters of the femoral vessels during V-A ECMO support, investigate differences between cannulated and non-cannulated vessels, and analyze the variations in the case of limb ischemia and intra-aortic balloon pumps (IABPs). Methods: Nineteen adults (≥18 years), supported with femoro-femoral V-A ECMO, underwent a duplex analysis of the superficial femoral arteries (SFAs) and veins (FVs). Measured parameters included flow velocities, waveforms, and vessel diameters. Results: 89% of patients had a distal perfusion cannula during duplex analysis and 21% of patients developed limb ischemia. The mean peak systolic flow velocity (PSV) and end-diastolic flow velocity (EDV) of the SFAs on the cannulated side were, respectively, 42.4 and 21.4 cm/s. The SFAs on the non-cannulated side showed a mean PSV and EDV of 87.4 and 19.6 cm/s. All SFAs on the cannulated side had monophasic waveforms, whereas 63% of the SFAs on the non-cannulated side had a multiphasic waveform. Continuous/decreased waveforms were seen in 79% of the FVs on the cannulated side and 61% of the waveforms of the contralateral veins were respirophasic. The mean diameter of the FVs on the cannulated side, in patients who developed limb ischemia, was larger compared to the FVs on the non-cannulated side with a ratio of 1.41 ± 0.12. The group without limb ischemia had a smaller ratio of 1.03 ± 0.25. Conclusions: Femoral cannulas influence flow velocities in the cannulated vessels during V-A ECMO and major waveforms alternations can be seen in all SFAs on the cannulated side and most FVs on the cannulated side. Our data suggest possible venous stasis in the FV on the cannulated side, especially in patients suffering from limb ischemia.

Introduction: Profoundly impaired left ventricular (LV) function in patients undergoing femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can result in intra-cardiac stasis and thrombus formation. There have been several attempts to improve LV unloading in patients with peripheral VA-ECMO, either by improving contractility or by venting the LV. Methods: Data from all patients who underwent femoral VA-ECMO between 2007 and 2015 due to cardiogenic decompensation were retrospectively analysed regarding intra-cardiac thrombus formation. Results: In total, 11 of 281 patients (3.91%) with femoral VA-ECMO developed an intra- or extra-cardiac thrombus despite adequate anticoagulation therapy. None of the patients survived this serious complication. Conclusion: Management strategies for patients with femoral VA-ECMO support and severely impaired LV function must be reassessed to avoid insufficient LV unloading at an early stage of ECMO therapy. Early LV decompression should be considered in patients with insufficient unloading of the LV to prevent intra-cardiac thrombus formation.

Background: Left ventricular (LV) afterload increase with protracted aortic valve (AV) closure may represent a complication of veno-arterial extracorporeal membrane oxygenation (V-A ECMO). The aim of the present study was to assess the effects of an intra-aortic balloon pump (IABP) to overcome such a hemodynamic shortcoming in patients submitted to peripheral V-A ECMO. Methods: Among 184 adult patients who were treated with peripheral V-A ECMO support at Medical University Center Maastricht Hospital between 2007 and 2018, patients submitted to IABP implant for protracted AV closure after V-A ECMO implant were retrospectively identified. All clinical and hemodynamic data, including echocardiographic monitoring, were collected and analyzed. Results: During the study period, 10 subjects (mean age 60 years old, 80% males) underwent IABP implant after peripheral V-A ECMO positioning due to the diagnosis of protracted AV closure and inefficient LV unloading as assessed by echocardiography and an absence of pulsation in the arterial pressure wave. Recovery of blood pressure pulsatility and enhanced LV unloading were observed in 8 patients after IABP placement, with no significant differences in the main hemodynamic parameters, inotropic therapy or in the ECMO flow (p=0.48). The weaning rate in this patient subgroup (mean ECMO duration 8 days), however, was only 10%, with another patient finally transplanted, leading to a 20% survival-to-hospital discharge. Conclusion: IABP placement was an effective solution in order to reverse the protracted AV closure and impaired LV unloading observed during peripheral V-A ECMO support. However, the impact on the weaning rate and survival needs further investigations.

La problématique de cette thèse est la caractérisation des complications liées à l’hémostase chez le patient assisté par ECMO-VA périphérique afin d’en améliorer la prévention et de rationaliser les approches antithrombotiques en usage. Dans une première étude, nous avons décrit qualitativement et quantitativement la composition des thrombi formés sur les circuits d’ECMO-VA. Nous avons observé que ces thrombi sont majoritairement composés de VWF, de fibrine et dans une moindre proportion de plaquettes et d’érythrocytes. Notre approche quantitative a également permis de mettre en évidence la présence de NETs en l’absence de toute pathologie septique active, confirmant la possibilité d’une NETose aseptique sous ECMO-VA. Par une analyse en cluster hiérarchique, nous avons identifié 2 types de thrombi pouvant relever chacun d’un mécanisme de formation différent. Dans cette étude, la localisation des thrombi sur le circuit d’ECMO-VA n’impactait pas leurs compositions, ce qui souligne l’hétérogénéité des thrombi formés sous ECMO-VA et la multiplicité des mécanismes à l’origine de la thrombinoformation dans ce contexte. Dans un second travail, nous avons comparé la performance des revêtements de surfaces des circuits d’ECMO-VA à réduire la thrombinoforation et ses conséquences cliniques. Deux des revêtements les plus utilisés en routine étaient comparés : celle à base de phosphorylcholine et à base d’héparine. Nous avons observé un taux de complications thrombotiques plus conséquent dans le groupe phosphorylcholine sans surrisque hémorragique ou de mortalité dans les deux groupes. Par ailleurs, comparativement aux thrombi issus des jonctions de circuits traités par revêtement de phosphorylcholine, ceux provenant de circuits traités par polysaccharide-albumine étaient plus pauvres en VWF. Notre travail suggère que l’intensité de l’anticoagulation devrait être modulée en fonction du type de revêtement de surface du circuit d’ECMO. Notre troisième étude avait pour but d’identifier les saignements les plus graves justifiants d’une prise en charge clinique agressive et d’un investissement plus conséquent en recherche. À cette fin, nous avons comparé l’association entre 3 classifications de saignement avec la mortalité à 28 jours. La définition ELSO déjà en usage et les classes de la classification BARC ≥ type 2 étaient associées à la mortalité et retenues donc comme définitions de l’hémorragie majeure. Les facteurs biologiques prédictifs de l’hémorragie grave d’après la définition de l’ELSO étaient la baisse du fibrinogène, du compte plaquettaire et de l’hémoglobine à la canulation. L’indice de masse corporelle et l’étiologie postcardiotomie étaient également prédictifs de la survenue de cette complication. Dans un travail additionnel portant sur la thématique de la thèse, nous avons étudié deux des tests les plus utilisés pour la surveillance de l’héparinothérapie systémique sous ECMO, le TCA et l’activité Anti-Xa afin d’identifier le plus pertinent. Pour ce faire, dans un premier objectif nous avons étudié la relation entre ces deux tests puis avons analysé dans un second objectif l’impact de facteurs biologiques d’influences sur cette relation. Ensuite, nous avons déterminé leurs associations avec les complications thrombotiques et hémorragiques. Bien qu’étant linéairement associé, le taux de discordance entre leurs mesures était de 39 % pour une fenêtre référence d’Anti-Xa de 0,3 — 0,7 UI/mL. Ni le TCA et ni l’Anti-Xa n’étaient associées aux complications thrombotiques ou hémorragiques [...]
The purpose of this dissertation is to characterize hemostasis-related complications in patients supported by peripheral VA-ECMO to improve their prevention and to optimize the antithrombotic therapeutic approaches in use. In a first study, we qualitatively and quantitatively described the composition of thrombi collected from the VA-ECMO circuits. We observed that these thrombi are mainly made of VWF, fibrin and in a lesser proportion of platelets and RBCs. Our quantitative approach also allowed us to demonstrate the presence of NETs while there was no active septic, confirming the possibility of aseptic NETosis under VA-ECMO. By hierarchical cluster analysis, we identified 2 types of thrombi, each of which may be related to a different mechanism of formation. In this study, the location of thrombi on the VA-ECMO circuit did not impact their compositions, highlighting the heterogeneity of thrombi formed within VA-ECMO and the multifactorial mechanisms that support thrombosis in this setting. In a second study, we compared the performance of surface coatings on VA-ECMO circuits to reduce thrombinoformation and its clinical consequences. Two of the most used coatings in daily practice were compared: the phosphorylcholin-based coating and the polysaccharide-albumin-based coating. We observed a higher rate of thrombotic complications in the phosphorylcholin group without any excess bleeding events or mortality in either group. In addition, compared with thrombi from phosphorylcholin-coated circuit junctions, those from polysaccharide-albumin-coated circuits were poorer in VWF. Our work suggests that the level of anticoagulation should be modulated according to the type of coating of the ECMO circuit.The aim of our third study was to identify the most relevant bleeding events that may guide clinical decision-making for more aggressive clinical management and a greater investment in research. To this end, we compared the association between 3 bleeding classifications with 28-day mortality. The ELSO definition already in use and the BARC classification classes ≥ type 2 were associated with 28-day mortality and thus retained as definitions of major bleeding. Laboratory parameters that are predictors major bleeding according to the ELSO definition were decreased fibrinogen, platelet count, and hemoglobin at cannulations. Body mass index and postcardiotomy etiology were also predictive of ELSO major bleeding. In an additional work related to the topic of the thesis, we studied two of the most used laboratory tests for the monitoring of systemic heparin during VA-ECMO, the APTT and the Anti-Xa activity, to identify the most relevant. First, we studied the relationship between these two tests and then analyzed in a second objective the impact of biological influencing factors on this relationship. Next, we determined their associations with thrombotic and hemorrhagic complications. Although linearly associated, the rate of discordance between their measurements was 39 % for an Anti-Xa reference range of 0.3 - 0.7 IU/mL. Neither APTT nor Anti-Xa was associated with thrombotic or bleeding complications. Taken together, our results highlight the heterogeneity of thrombi from peripheral VA-ECMO, the involvement of numerous causal factors that underline thrombotic and hemorrhagic complications, both not predictable by routine tests. Finally, our work underscored the need for new approaches in thrombotic or hemorrhagic complications management with targets set at an individual level considering both patient and ECMO circuit characteristics

Treatment with extracorporeal membrane oxygenation (ECMO) has increased tremendously during the last decade due to high survival rates during the H1N1 2009 pandemic and positive technical development. ECMO is used in the veno-venous configuration (V-V ECMO) for pulmonary support in severe respiratory failure with preserved cardiac function or as veno-arterial ECMO (V-A ECMO) to bypass the heart and lungs during cardiac failure with or without pulmonary support. Neurological complications after critical illness occur frequently. Short-term mortality and long-term disabilities are high in patients with neurological complications. Some of these complications may be directly related to ECMO treatment (e.g., intracranial hemorrhage, stroke, and peripheral nerve lesions). This chapter presents a virtual case of a patient who presented with neurological sequelae after being treated with V-V and V-A ECMO for severe respiratory failure with circulatory complications. Diagnosis, treatment options, and possible prophylactic measures are developed through questions and answers regarding the case, followed by a discussion of the current available literature and clinical experiences. At the end of this chapter, nine review questions give the opportunity to test the learning outcome of this chapter.

Extracorporeal membrane oxygenation (ECMO), a form of extracorporeal life support (ECLS), represents a life-saving intervention in patients with cardiac and/or respiratory failure not responding to medical therapy. Blood is drained from a central vein (V), pumped through a membrane oxygenator for oxygenation and CO₂ removal, and ultimately returned into a central vein or artery (A). Veno-arterial (V-A) ECMO is primarily used for patients in cardiogenic shock and provides both hemodynamic and respiratory support. V-A ECMO can limit or prevent secondary end-organ damage and allow time for myocardial recovery while a decision is made for the best definitive treatment. Conventional peripheral V-A ECMO, that is, return via femoral artery, carries the risks of differential oxygenation with upper body hypoxemia and extremity ischemia. Veno-venous (V-V) ECMO can rescue patients with the most severe respiratory failure but does not provide hemodynamic support. V-V ECMO allows for lung rest in patients who otherwise would receive potentially injurious ventilator support. Both V-A and V-V ECMO are invaluable, life-saving tools in patients who are failing maximum medical therapy.

Postcardiotomy (cardiac surgery) refractory cardiogenic shock after cardiac arrest is commonly a fatal condition. In some instances an intra-aortic balloon pump may bridge the failing heart to recovery. However, a stunned myocardium often requires a period of rest only provided through mechanical circulatory support. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) works just like the standard cardiopulmonary bypass by draining blood from the venous system and returns it into the systemic circulation, hence providing immediate cardiorespiratory support. Failure to achieve spontaneous circulation after cardiac arrest in this situation is an indication for open cardiac massage and institution of either central or peripheral V-A ECMO. V-A ECMO is potentially a life-saving modality in this acute setting. It provides survival benefit with reasonable intermediate and long-term outcomes; however, survival of less than 50% is often expected. Death is commonly caused by complications that lead to multiorgan dysfunction. Hence, a high index of suspicion is needed for the early diagnosis and treatment of associated complications.