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1
Biancari, Fausto, Alexander Kaserer, Andrea Perrotti, Vito G. Ruggieri, Sung-Min Cho, Jin Kook Kang, Magnus Dalén, et al. "Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis." Journal of Clinical Medicine 11, no. 24 (December 14, 2022): 7406. http://dx.doi.org/10.3390/jcm11247406.
Анотація:
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.
2
Rao, Prashant, Jarrod Mosier, Joshua Malo, Vicky Dotson, Christopher Mogan, Richard Smith, Roy Keller, Marvin Slepian, and Zain Khalpey. "Peripheral VA-ECMO with direct biventricular decompression for refractory cardiogenic shock." Perfusion 33, no. 6 (February 21, 2018): 493–95. http://dx.doi.org/10.1177/0267659118761558.
Анотація:
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.
3
Blandino Ortiz, Aaron, Mirko Belliato, Lars Mikael Broman, Olivier Lheureux, Maximilian Valentin Malfertheiner, Angela Xini, Federico Pappalardo, and Fabio Silvio Taccone. "Early Findings after Implementation of Veno-Arteriovenous ECMO: A Multicenter European Experience." Membranes 11, no. 2 (January 22, 2021): 81. http://dx.doi.org/10.3390/membranes11020081.
Анотація:
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.
4
Andrei, Stefan, Maxime Nguyen, Vivien Berthoud, Bastian Durand, Valerian Duclos, Marie-Catherine Morgant, Olivier Bouchot, Belaid Bouhemad, and Pierre-Grégoire Guinot. "Determinants of Arterial Pressure of Oxygen and Carbon Dioxide in Patients Supported by Veno-Arterial ECMO." Journal of Clinical Medicine 11, no. 17 (September 4, 2022): 5228. http://dx.doi.org/10.3390/jcm11175228.
Анотація:
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.
5
Rodriguez, Maria L., and Gyaandeo Maharajh. "Long venous cannula on the arterial position for VA-ECMO." Perfusion 33, no. 6 (April 6, 2018): 423–25. http://dx.doi.org/10.1177/0267659118765628.
Анотація:
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.
6
Chang, Hsiao-Huang, Kai-Hsiang Hou, Ting-Wei Chiang, Yi-Min Wang, and Chia-Wei Sun. "Using Signal Features of Functional Near-Infrared Spectroscopy for Acute Physiological Score Estimation in ECMO Patients." Bioengineering 11, no. 1 (December 26, 2023): 26. http://dx.doi.org/10.3390/bioengineering11010026.
Анотація:
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.
7
Simons, Jorik, Sandra Agricola, Jeroen Smets, Renske Metz, Silvia Mariani, Marie-José Vleugels, Reinier R. Smeets, Walther N. K. A. van Mook, Barend Mees, and Roberto Lorusso. "Duplex Analysis of Cannulated Vessels in Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation." Medicina 58, no. 5 (May 18, 2022): 671. http://dx.doi.org/10.3390/medicina58050671.
Анотація:
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.
8
Spirina, E. A., R. S. Saitgareev, D. V. Shumakov, V. M. Zakharevitch, V. V. Slobodyannik, M. G. Minina, V. V. Pchelnikov, O. A. Eremeeva, and P. G. Lavrenov. "PERIPHERAL VENO-ARTERIAL ECMO AS MECHANICAL CIRCULATORY SUPPORT BEFORE HEART TRANSPLANTATION." Russian Journal of Transplantology and Artificial Organs 15, no. 2 (May 16, 2014): 23. http://dx.doi.org/10.15825/1995-1191-2013-2-23-35.
9
Weber, Carolyn, Antje-Christin Deppe, Anton Sabashnikov, Ingo Slottosch, Elmar Kuhn, Kaveh Eghbalzadeh, Maximilian Scherner, Yeong-Hoon Choi, Navid Madershahian, and Thorsten Wahlers. "Left ventricular thrombus formation in patients undergoing femoral veno-arterial extracorporeal membrane oxygenation." Perfusion 33, no. 4 (November 24, 2017): 283–88. http://dx.doi.org/10.1177/0267659117745369.
Анотація:
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.
10
Meani, Paolo, Thijs Delnoij, Giuseppe M. Raffa, Nuccia Morici, Giovanna Viola, Alice Sacco, Fabrizio Oliva, et al. "Protracted aortic valve closure during peripheral veno-arterial extracorporeal life support: is intra-aortic balloon pump an effective solution?" Perfusion 34, no. 1 (July 19, 2018): 35–41. http://dx.doi.org/10.1177/0267659118787426.
Анотація:
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.
11
Brockaert, Tifanie, Inês Ferreira, Anne Laplante, Paul Fogel, David Grimbert, and Pierre Mordant. "Preventing Acute Limb Ischemia during VA-ECMO—In Silico Analysis of Physical Parameters Associated with Lower Limb Perfusion." Journal of Clinical Medicine 12, no. 18 (September 19, 2023): 6049. http://dx.doi.org/10.3390/jcm12186049.
Анотація:
Background: Peripheral femoro-femoral veno-arterial extracorporeal membrane oxygenation is increasingly used in refractory cardiogenic shock. However, the obstruction of the femoral artery by the return cannula could lead to acute limb ischemia, a frequently encountered situation that is inconstantly prevented by the adjunction of a distal perfusion cannula (DPC). The aim of this study was to investigate the influence of three physical parameters on the perfusion of the cannulated lower limb. Methods: Using patient-specific arterial models and computational fluid dynamic simulations, we studied four diameters of arterial cannula, three diameters of DPC, and two percentages of arterial section limitation. Results: We found that adequate perfusion of the cannulated limb was achieved in only two out of the twenty-one configurations tested, specifically, when the arterial cannula had a diameter of 17 Fr, was considered to limit the section of the artery by 90%, and was associated with an 8 Fr or a 10 Fr DPC. Multivariable analysis revealed that the perfusion of the cannulated lower limb was correlated with the diameter of the DPC, but also with the diameter of the arterial cannula and the percentage of arterial section limitation. Conclusions: In most of the cases simulated here, the current system combining unsized arterial cannula and non-specific DPC was not sufficient to provide adequate perfusion of the cannulated lower limb, urging the need for innovative strategies to efficiently prevent acute limb ischemia during peripheral femoro-femoral veno-arterial extracorporeal membrane oxygenation.
12
Efrimescu, Catalin Iulian, Don M. Walsh, Jehan Zeb Chughtai, and Thomas P. Wall. "Preoperative initiation of peripheral veno-arterial extracorporeal membrane oxygenation for a complex case of cardiac tamponade." BMJ Case Reports 16, no. 9 (September 2023): e253913. http://dx.doi.org/10.1136/bcr-2022-253913.
Анотація:
In this case report, we present an alternative approach to the anaesthetic management of patients presenting with delayed postoperative cardiac tamponade physiology. Given that pericardiocentesis was deemed unsafe, and a protracted surgical dissection was anticipated, peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was established prior to induction of anaesthesia to prevent catastrophic circulatory failure. To the best of our knowledge, this is the first reported case of planned preoperative commencement of peripheral VA-ECMO in a complex case of cardiac tamponade. We discuss the challenges associated with this case and the process for selecting this strategy. We also describe the role of transoesophageal echocardiography in planning the surgical approach. This report is completed by a discussion on the topic of delayed postoperative pericardial effusion and tamponade.
13
Djordjevic, Ilija, Oliver Liakopoulos, Mara Elskamp, Johanna Maier-Trauth, Stephen Gerfer, Thomas Mühlbauer, Ingo Slottosch, et al. "Concomitant Intra-Aortic Balloon Pumping Significantly Reduces Left Ventricular Pressure during Central Veno-Arterial Extracorporeal Membrane Oxygenation—Results from a Large Animal Model." Life 12, no. 11 (November 12, 2022): 1859. http://dx.doi.org/10.3390/life12111859.
Анотація:
(1) Introduction: Simultaneous ECMO and IABP therapy is frequently used. Haemodynamic changes responsible for the success of the concomitant mechanical circulatory support system approach are rarely investigated. In a large-animal model, we analysed haemodynamic parameters before and during ECMO therapy, comparing central and peripheral ECMO circulation with and without simultaneous IABP support. (2) Methods: Thirty-three female pigs were divided into five groups: (1) SHAM, (2) (peripheral)ECMO(–)IABP, (3) (p)ECMO(+)IABP, (4) (central)ECMO(–)IABP, and (5) (c)ECMO(+)IABP. Pigs were cannulated in accordance with the group and supported with ECMO (±IABP) for 10 h. Systemic haemodynamics, cardiac index (CI), and coronary and carotid artery blood flow were determined before, directly after, and at five and ten hours on extracorporeal support. Systemic inflammation (IL-6; IL-10; TNFα; IFNγ), immune response (NETs; cf-DNA), and endothelial injury (ET-1) were also measured. (3) Results: IABP support during antegrade ECMO circulation led to a significant reduction of left ventricular pressure in comparison to retrograde flow in (p)ECMO(–)IABP and (p)ECMO(+)IABP. Blood flow in the left anterior coronary and carotid artery was not affected by extracorporeal circulation. (4) Conclusions: Concomitant central ECMO and IABP therapy leads to significant reduction of intracavitary cardiac pressure, reduces cardiac work, and might therefore contribute to improved recovery in ECMO patients.
14
Kang, Soyoung, Seungwon Yang, Jongsung Hahn, June Young Jang, Kyoung Lok Min, Jin Wi, and Min Jung Chang. "Dose Optimization of Meropenem in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation in Critically Ill Cardiac Patients: Pharmacokinetic/Pharmacodynamic Modeling." Journal of Clinical Medicine 11, no. 22 (November 8, 2022): 6621. http://dx.doi.org/10.3390/jcm11226621.
Анотація:
Background: Our objective was to determine an optimal dosage regimen of meropenem in patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) by developing a pharmacokinetic/pharmacodynamic (PK/PD) model. Methods: This was a prospective cohort study. Blood samples were collected during ECMO (ECMO-ON) and after ECMO (ECMO-OFF). The population pharmacokinetic model was developed using nonlinear mixed-effects modeling. A Monte Carlo simulation was used (n = 10,000) to assess the probability of target attainment. Results: Thirteen adult patients on ECMO receiving meropenem were included. Meropenem pharmacokinetics was best fitted by a two-compartment model. The final pharmacokinetic model was: CL (L/h) = 3.79 × 0.44CRRT, central volume of distribution (L) = 2.4, peripheral volume of distribution (L) = 8.56, and intercompartmental clearance (L/h) = 21.3. According to the simulation results, if more aggressive treatment is needed (100% fT > MIC target), dose increment or extended infusion is recommended. Conclusions: We established a population pharmacokinetic model for meropenem in patients receiving V-A ECMO and revealed that it is not necessary to adjust the dosage depending on V-A ECMO. Instead, more aggressive treatment is needed than that of standard treatment, and higher dosage is required without continuous renal replacement therapy (CRRT). Also, extended infusion could lead to better target attainment, and we could provide updated nomograms of the meropenem dosage regimen.
15
Poptsov, Vitaly, Ekaterina Spirina, Anastasiya Dogonasheva, and Elizaveta Zolotova. "Five years’ experience with a peripheral veno-arterial ECMO for mechanical bridge to heart transplantation." Journal of Thoracic Disease 11, S6 (April 2019): S889—S901. http://dx.doi.org/10.21037/jtd.2019.02.55.
16
Poptsov, V. N., E. A. Spirina, R. S. Saitgareev, V. M. Zakharevich, O. A. Eremeeva, and S. A. Masyutin. "Peripheral Veno-Arterial ECMO as a Bridge To Heart Transplantation: Outcomes From a Single-Centre Experience." Journal of Heart and Lung Transplantation 33, no. 4 (April 2014): S247—S248. http://dx.doi.org/10.1016/j.healun.2014.01.647.
17
Poptsov, V. N., V. M. Zakharevich, E. A. Spirina, A. I. Skokova, A. K. Solodovnikova, A. S. Ignatkina, A. A. Kuznetsova, and G. B. Glinkin. "Strategy for prophylactic application of peripheral va-ecmo in transplantation involving expected extremely prolonged ischemia time." Russian Journal of Transplantology and Artificial Organs 26, no. 1 (December 18, 2023): 55–66. http://dx.doi.org/10.15825/1995-1191-2024-1-55-66.
Анотація:
Heart transplantation (HT) with extremely prolonged (>6 hours) graft ischemia is associated with severe cardiac graft dysfunction. The high efficiency of prophylactic (preoperative initiation) veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to prevent severe hemodynamic disorders during cardiac surgery has been demonstrated. Objective: to determine the effect of prophylactic VA-ECMO on the perioperative period in HT with an expected graft ischemia >6 hours. Materials and methods. Thirty-eight recipients (33 (86.8%) males and 5 (13.2%) females), age 11–66 (44.7 ± 12.0) years (median 48.0 years) were examined. Pre-transplant mechanical circulatory support (MCS) using peripheral VA-ECMO was applied in 15 (39.5%) recipients, in 6 of whom by prophylactic technique. The recipients (n = 38) were divided into 3 groups: 1) «no pre-HT VA-ECMO» (n = 23); 2) «pre-HT VA-ECMO» (n = 9) – pre-transplant VA-ECMO as a bridge to HT; 3) «prophylactic VA-ECMO» (n = 6). Results. In «prophylactic VA-ECMO» group, extracorporeal circulation (ECC) (94.0 [85.5; 102.8] min) and reperfusion time (20.0 [18.3; 27.6] min) were shorter (p < 0.05) compared to «no pre-HT VA-ECMO» (161.0 [122; 191.5] and 60.0 [55.3; 70.5] min) and «pre-HT VA-ECMO» (127.0 [117; 150.3] and 35.0 [27.8; 48.8] min) groups. The vasoactive-inotropic score was lower (p < 0.05) in «pre-HT VA-ECMO» and «prophylactic VAECMO» groups compared to recipients in «no pre-HT VA-ECMO» group, 12.1 [11.2; 14.0] and 12.5 [11.7; 14.8] vs. 16.0 [15.0; 18.5], respectively. The groups did not differ in terms of incidence of severe primary dysfunction. The «pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups were characterized by shorter duration of mechanical ventilation (MV) compared with «no pre-HT VA-ECMO» group (11.7 [10.0; 16.5] and 12.7 [11.3; 18.4], respectively, vs. 14.5 [13.0; 19.3]). The «no pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups did not differ in the need for postoperative MST, 21.7% and 16.7%, respectively. The groups did not differ in terms of length of stay in the intensive care unit (ICU) and in-hospital mortality – 0% («prophylactic VA-ECMO») and 8.7% («no pre-HT VA-ECMO») and 11.1% («pre-HT VA-ECMO»), respectively. Conclusion. Prophylactic VA-ECMO in HT with extremely prolonged cardiac graft ischemia reduces ECC duration, reperfusion period, postoperative mechanical ventilation period, and the need for inotropic therapy.
18
Centofanti, Paolo, Matteo Attisani, Michele La Torre, Davide Ricci, Massimo Boffini, Andrea Baronetto, Erika Simonato, Alberto Clerici, and Mauro Rinaldi. "Left Ventricular Unloading during Peripheral Extracorporeal Membrane Oxygenator Support: A Bridge To Life In Profound Cardiogenic Shock." Journal of ExtraCorporeal Technology 49, no. 3 (September 2017): 201–5. http://dx.doi.org/10.1051/ject/201749201.
Анотація:
A limit of peripheral veno-arterial Extracorporeal Membrane Oxigenator (VA-ECMO) is the inadequate unloading of the left ventricle. The increase of end-diastolic pressure reduces the possibility of a recovery and may cause severe pulmonary edema. In this study, we evaluate our results after implantation of VA-ECMO and Transapical Left Ventricular Vent (TLVV) as a bridge to recovery, heart transplantation or long-term left ventricular assit devices (LVAD). From 2011 to 2014, 24 consecutive patients with profound cardiogenic shock were supported by peripheral VA-ECMO as bridge to decision. In all cases, TLVV was implanted after a mean period of 12.2 ± 3.4 hours through a left mini-thoracotomy and connected to the venous inflow line of the VA-ECMO. Thirty-day mortality was 37.5% (9/24). In all patients, hemodynamics improved after TLVV implantation with an increased cardiac output, mixed venous saturation and a significant reduced heart filling pressures (p < .05). Recovery of the cardiac function was observed in 11 patients (11/24; 45.8%). Three patients were transplanted (3/24; 12.5%) and three patients (3/24; 12.5%) underwent LVAD implantation as destination therapy, all these patients were discharged from the hospital in good clinical conditions. In these critical patients, systematic TLVV improved hemodynamic seemed to provide better in hospital survival and chance of recovery, compared to VA-ECMO results in the treatment of cardiogenic shock reported in the literature . TLVV is a viable alternative to standard VA-ECMO to identify the appropriate long-term strategy (heart transplantation or long-term VAD) reducing the risk of treatment failure. A larger and multicenter experience is mandatory to validate these hypothesis.
19
Poptsov, V. N., V. M. Zakharevich, E. A. Spirina, S. G. Uhrenkov, A. A. Dogonasheva, and E. Z. Aliev. "Outcomes and risk factors of mechanical circulatory support by peripheral venoarterial extracorporeal membrane oxygenation in heart transplant candidates needing urgent heart transplantation." Russian Journal of Transplantology and Artificial Organs 19, no. 4 (January 30, 2018): 54–60. http://dx.doi.org/10.15825/1995-1191-2017-4-54-60.
Анотація:
Introduction Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) is one of the most frequently used methods of temporary mechanical circulatory support (MCS) at patients with life-threatening circulatory derangement.Aim: to evaluate the effectiveness and risk factors of peripheral VA ECMO in patients waiting of urgent heart transplantation (HT). Materials and methods. The study included 149 (129 (86.6%) men and 20 (13.4%) women, age 12 to 72 (43.0 ± 1.2) years) heart transplant candidates who in the period 01.01.2011–31.12.2016 were supported by peripheral VA ECMO. These patients were 21.1% of the total waiting list (n = 706) of our institute at the same period. Indication for MCS by VA ECMO was advanced heart failure corresponding to I or II level of INTERMACS classifi cation.Results. 135 (90.6%) from 149 patients were successfully supported to HT. 14 (9.4%) deed following MCS. Before of VA ECMO these patients (n = 14) had more severe (p < 0.05) hemodynamic disorders, organ dysfunction, electrolyte and metabolic disorders compared to patients TC successfully supported to HT. Left atrium (n = 24)/left ventricle drainage (n = 8) was performed for volume decompression of left heart (n = 32 (21.5%)). In a single-factor analysis, statistically signifi cant pre VA ECMO risk factors for the lethal outcome were: creatinine ≥ 140 mmol/l, urea ≥ 15 mmol/l, total bilirubin ≥ 80 μmol/l, ALT ≥ 300 U/l, AST ≥ 300 U/l, INR ≥ 3.0, procalcitonin ≥ 3.0 ng/ml, preexisting left ventricular thrombosis complicated thromboembolic stroke with brain death following VA ECMO (n = 3). Statistically signifi cant factors for the lethal outcome following MCS were: transthoracic left ventricle drainage (n = 8) compared to transcutaneous transfemoral transseptal left atrium drainage (n = 24) for volume decompression of left heart; hemolysis ≥ 300 mg%. Conclusion. VA ECMO is high effi ciency method of temporary MCS in 90.6% heart transplant candidates needed at urgent HT. VA ECMO must be begin before development of potential lethal multiorgan and septic complications. Preexisting left ventricular thrombosis increase risk of lethal thromboembolic brain injury following VA ECMO. Patients with transcutaneous transfemoral transseptal left atrium drainage for left heart volume decompression had better outcome following MCS by VA ECMO.
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Poptsov, V. N., E. A. Spirina, and A. A. Dogonascheva. "Five Years Experience of Peripheral Veno-Arterial ECMO as Method of Mechanical Circulatory Support in Heart Transplant Candidates." Journal of Heart and Lung Transplantation 39, no. 4 (April 2020): S14. http://dx.doi.org/10.1016/j.healun.2020.01.1135.
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Gerfer, Stephen, Ilija Djordjevic, Johanna Maier, Ana Movahed, Mara Elskamp, Elmar Kuhn, Oliver Liakopoulos, Thorsten Wahlers, and Antje C. Deppe. "Endothelial and Hemodynamic Function in a Large Animal Model in Relation to Different Extracorporeal Membrane Oxygenation Cannulation Strategies and Intra-Aortic Balloon Pumping." Journal of Clinical Medicine 12, no. 12 (June 13, 2023): 4038. http://dx.doi.org/10.3390/jcm12124038.
Анотація:
Background: The use of simultaneous veno-arterial extracorporeal membrane oxygenation (ECMO) with or without an Intra-Aortic Balloon Pump (IABP) is a widely used tool for mechanical hemodynamic support. Endothelial function, especially in relation to different cannulation techniques, is rarely investigated in the setting of extracorporeal life support (ECLS). In this study, we analyzed endothelial function in relation to hemodynamic and laboratory parameters for central and peripheral ECMO, with or without concomitant IABP support in a large animal model to gain a better understanding of the underlying basic mechanisms. Methods: In this large animal model, healthy female pigs with preserved ejection fraction were divided into the following groups related to cannulation strategy for ECMO and simultaneous IBAP support: control (no ECMO, no IABP), peripheral ECMO (pECMO), central ECMO (cECMO), pECMO and IABP or cECMO and IABP. During the experimental setting, the blood flow in the ascending aorta, left coronary artery and arteria carotis was measured. Afterwards, endothelial function was investigated after harvesting the right coronary artery, arteria carotis and renal artery. In addition, laboratory markers, such as creatine kinase (CK), creatine kinase muscle–brain (CK-MB), troponin, creatinine and endothelin were analyzed. Results: The blood flow in the ascending aorta and the left coronary artery was significantly lower in all discussed experimental settings compared to the control group. Of note, the cECMO cannulation strategy generated favorable hemodynamic circumstances with higher blood flow in the coronary arteries than pECMO regardless of flow circumstances in the ascending aorta. The concomitant usage of IABP did not result in an improvement of the coronary blood flow, but partially showed a negative impact on the endothelial function of coronary arteries in comparison to the control. These findings correlate to higher CK/CK-MB levels in the setting of cECMO + IABP and pECMO + IABP. Conclusions: The usage of mechanical circulatory support with concomitant ECMO and IABP in a large animal model might have an influence on the endothelial function of coronary arteries while not improving the coronary artery perfusion in healthy hearts with preserved ejection.
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Kulyassa, Péter, Balázs Tamás Németh, István Hartyánszky, Bálint Szilveszter, Levente Fazekas, Miklós Pólos, Endre Németh, Dávid Becker, Béla Merkely, and István Ferenc Édes. "A VA-ECMO használata, tapasztalatok a Városmajori Klinikán." Cardiologia Hungarica 51, no. 5-6 (2021): 320–30. http://dx.doi.org/10.26430/chungarica.2021.51.5.320.
Анотація:
Mechanical circulatory support (MCS) was introduced in the 1960s, of which there is short-, mid- and long-term forms. This brief review discusses our experiences with the primary modality used in Hungary, the veno-arterial extracorporeal membrane oxygenator (VA-ECMO). We introduced the device with the most relevant information and summarized our clinic’s registry with patient characteristics and results in whom we applied this modality next to data of international studies. We collected data retro- and prospectively from 2012 to 2020 from patients treated with the VA-ECMO at our clinic. The primary endpoint we used was all cause mortality in this patient population of critical condition. Every indication, potential peripheral-central conversion and primary operation technique was involved in the analysis. We found that age above 65 and initial pH under 7.2 significantly affects mortality data. Acute coronary syndrome (ACS) as primary indication showed to be nearly significant, and acute rejection after hTX was a beneficial clinical scenario regarding survival. In international literature diabetes mellitus, elevated levels of lactate, kidney- and hepatic insufficiency were identified as contributing mortality predictors as well. Our results mostly coincide with the international mortality and risk factor data. Time is a very important factor for the survival of these patients. Therefore, it is very important to refer the patient’s refractory to non-MCS therapy to centers with VA-ECMO capability in time.
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Fernandes, Philip, Michael O’Neil, Samantha Del Valle, Anita Cave, and Dave Nagpal. "A 24-hour perioperative case study on argatroban use for left ventricle assist device insertion during cardiopulmonary bypass and veno-arterial extracorporeal membrane oxygenation." Perfusion 34, no. 4 (December 25, 2018): 337–44. http://dx.doi.org/10.1177/0267659118813043.
Анотація:
A 44-year-old male with ongoing chest pain and left ventricular ejection fraction <20% was transferred from a peripheral hospital with intra-aortic balloon pump placement following a non-ST-elevation myocardial infarction (STEMI). The patient underwent emergent multi-vessel coronary artery bypass grafting requiring veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) on post-operative day (POD)#9 secondary to cardiogenic shock with biventricular failure. Due to clot formation, an oxygenator change-out was necessary shortly after initiation. Following a positive heparin-induced thrombocytopenia (HIT) assay, a total circuit exchange was required to eliminate all heparin coating and argatroban was deemed the anticoagulant of choice due to acute kidney injury. On POD#24, the decision was made to implant a left ventricle assist device (LVAD) as a bridge to heart transplantation. There was difficulty achieving an activated clotting time (ACT) >400 s: multiple argatroban bolus doses were required, along with accelerated up-titration of infusion dosing. Despite maintaining an ACT >484 s, clot formation was observed in the cardiotomy reservoir prior to separation. Subsequently, the patient developed severe disseminated intravascular coagulopathy, with both intra-cardiac and intravascular thrombi, requiring massive transfusion and continuous cell saving due to severe hemorrhage post cardiopulmonary bypass (CPB). The patient received a total of 105 units of plasma, 74 units of packed red cells, 19 units of platelets, 13 bottles of 5% albumin, 6 units of cryoprecipitate and 2 doses of factor VIIa intraoperatively over the course of 24 hours. A total of 19.7 L of washed red blood cells were returned to the patient from the cell saver. With the LVAD in place, the patient developed transfusion-related acute lung injury and acute respiratory distress syndrome with right ventricular dysfunction requiring VA ECMO once again. On POD#30, ECMO was discontinued and the patient was discharged from the intensive care unit (ICU) on POD 66. After a very complex post-operative stay with numerous surgeries and extensive rehabilitation, the patient was discharged home with the LVAD on POD#112.
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Haertel, Franz, Thomas Lehmann, Tabitha Heller, Michael Fritzenwanger, Ruediger Pfeifer, Daniel Kretzschmar, Sylvia Otto, et al. "Impact of a VA–ECMO in Combination with an Extracorporeal Cytokine Hemadsorption System in Critically Ill Patients with Cardiogenic Shock–Design and Rationale of the ECMOsorb Trial." Journal of Clinical Medicine 12, no. 15 (July 25, 2023): 4893. http://dx.doi.org/10.3390/jcm12154893.
Анотація:
Background: Cardiogenic shock and arrest present as critical, life-threatening emergencies characterized by severely compromised tissue perfusion and inadequate oxygen supply. Veno–arterial extracorporeal membrane oxygenation (VA–ECMO) serves as a mechanical support system for patients suffering shock refractory to conventional resuscitation. Despite the utilization of VA–ECMO, clinical deterioration due to systemic inflammatory response syndrome (SIRS) resulting from the underlying shock and exposure of blood cells to the artificial surfaces of the ECMO circuit may occur. To address this issue, cytokine adsorbers offer a valuable solution by eliminating blood proteins, thereby controlling SIRS and potentially improving hemodynamics. Consequently, a prospective, randomized, blinded clinical trial will be carried out with ECMOsorb. Methods and Study Design: ECMOsorb is a single-center, controlled, randomized, triple-blinded trial that will compare the hemodynamic effects of treatment with a VA–ECMO in combination with a cytokine adsorber (CytoSorb®, intervention) to treatment with VA–ECMO only (control) in patients with cardiogenic shock (with or without prior cardiopulmonary resuscitation (CPR)) requiring extracorporeal, hemodynamic support. Fifty-four patients will be randomized in a 1:1 fashion to the intervention or control group over a 36-month period. The primary endpoint of ECMOsorb is the improvement of the Inotropic Score (IS) 72 h after the intervention. Prognostic indicators, including mortality rates, hemodynamic parameters, laboratory findings, echocardiographic assessments, quality of life measurements, and clinical parameters, will serve as secondary outcome measures. The safety evaluation encompasses endpoints such as air embolisms, allergic reactions, peripheral ischemic complications, vascular complications, bleeding incidents, and stroke occurrences. Conclusions: The ECMOsorb trial seeks to assess the efficacy of a cytokine adsorber (CytoSorb®; CytoSorbents Europe GmbH, Berlin, Germany) in reducing SIRS and improving hemodynamics in patients with cardiogenic shock who are receiving VA–ECMO. We hypothesize that a reduction in cytokine levels can lead to faster weaning from inotropic and mechanical circulatory support, and ultimately to improved recovery.
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Ellauzi, Rama, Parul Kochhar, Raef A. Fadel, Stacy Willner, Babar B. Basir, and Jennifer Cowger. "D-20 | Gender Differences in the Utilization and Outcomes of Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO): A Single Center Study." Journal of the Society for Cardiovascular Angiography & Interventions 3, no. 5 (May 2024): 101714. http://dx.doi.org/10.1016/j.jscai.2024.101714.
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Mehta, Vipin, and Rajamiyer V. Venkateswaran. "Outcome of CentriMag™ extracorporeal mechanical circulatory support use in critical cardiogenic shock (INTERMACS 1) patients." Indian Journal of Thoracic and Cardiovascular Surgery 36, S2 (August 2020): 265–74. http://dx.doi.org/10.1007/s12055-020-01060-6.
Анотація:
Abstract Purpose Prognosis of patients presenting with INTERMACS 1 critical cardiogenic shock is generally poor. The aim of our study was to investigate the results of CentriMag™ extracorporeal short-term mechanical circulatory support as a bridge to decision in patients presenting with critical cardiogenic shock in our unit. Methods We retrospectively analysed 63 consecutive patients from January 2005 to June 2017, who were treated with a CentriMag™ device at our institution as a bridge to decision. Patients requiring extracorporeal support for post-cardiotomy shock and for primary graft dysfunction after heart transplantation were excluded. Results Patients’ median age was 44 years (IQR 31–52, range 15.4–62.0) and 42 (67%) were male. Primary diagnosis at presentation was ischaemic cardiomyopathy (n = 24; 38.1%), viral myocarditis (n = 19; 30.2%), idiopathic dilated cardiomyopathy (n = 8; 12.7%), and others (n = 12; 19%). The median duration of support was 25 (IQR 9.5–56) days. A total of 7 (11%) patients were supported with peripheral veno-arterial (VA) extra corporeal membrane oxygenation (ECMO), 6 (9%) with central VA ECMO, 8 (13%) with left ventricular assist device (LVAD), 17 (27%) with biventricular assist device (BiVAD), and 25 (40%) with ECMO and then converted to BiVAD. Overall, 22 (34.9%) patients died while on CentriMag™ mechanical circulatory support. Complications included bleeding requiring reoperation/intervention in 24 (38%), renal failure requiring dialysis in 29 (46%), bacterial infections in 23 (37%), fungal infections in 15 (24%), critical limb ischaemia in 6 (10%), and stroke in 8 (13%). The overall survival to successful explant from CentriMag™ was 65.1% (n = 41) and survival to hospital discharge was 58.7% (n = 37). Of these, 10 (16%) had cardiac recovery and were successfully explanted, 20 (32%) were bridged to heart transplantation, 11 (17%) were bridged to long-term left ventricular assist device, 3 (4.7%) were later on transplanted, and 1 (1.6%) recovered to decommissioning. The 1-, 5-, and 10-year survival rates were 55%, 46%, and 23% respectively. Conclusion Our results demonstrate an excellent outcome with the use of the CentriMag™ device in this seriously ill population. Despite requiring multiple procedures, over 58% of patients were discharged from hospital with 5-year survival of 46%.
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Fusi, C., A. Marchese, C. Sorini Dini, F. Righini, F. Cesareo, R. Gentilini, S. Bernazzali, M. Maccherini, and S. Valente. "MONOCENTRIC EXPERIENCE FROM A CARDIOGENIC SHOCK NETWORK: ROLE OF ECLS IN REFRACTORY CARDIOGENIC SHOCK, KEY TO SURVIVAL OR BRIDGE TO ADVANCED HEART FAILURE THERAPIES." European Heart Journal Supplements 26, Supplement_2 (April 2024): ii136. http://dx.doi.org/10.1093/eurheartjsupp/suae036.341.
Анотація:
Abstract Background Extra–Circulatory Life Support (ECLS) is a vital therapeutic option in patients (pts) with refractory cardiogenic shock (CS). Few centers can assure optimal assistance to these delicate pts and early centralization in the context of regional networks is essential. Methods We enrolled all consecutive pts with ECLS for refractory CS admitted to our Intensive Cardiac Care Unit (ICCU) from January 2021 to November 2023. The primary endpoints evaluated were weaning from ECLS and in–hospital mortality. The secondary endpoints included neurological outcomes and major complications. Results We enrolled 21 consecutive pts (90% male, 55y median age) with refractory CS and indication for peripheral Veno–Arterial Extracorporeal Membrane Oxygenation (VA–ECMO), percutaneously or surgically positioned, with antegrade perfusion to avoid limb ischemia. Fourteen pts (67%) came from other hospitals, 8 (38%) of which already had been implanted with ECLS. Concerning the CS etiology, we observed 8 (38%) heart failure, 12 (57%) post–myocardial infarction, 1 (5%) adrenergic storm and 10 (48%) cardiac arrests. Six pts (28%) were deemed eligible for heart transplant (HT) list before the CS episode. In all pts we assured left ventricle unloading with IABP (9), Impella CP (3), Impella 5.5 (1). Five pts underwent apical left ventricular venting and escalation of mechanical support. The median duration of ECLS support was 10.1 days. Eleven pts (52%) were successfully weaned from VA–ECMO due to myocardial recovery (n=6; 29%) or HT (n=5; 24%); of the latter, 1 died due to peri–operative complication. Overall in–hospital mortality rate was 52%. Ten pts were discharged: 7 without neurological deficit (CPC 1), 2 with mildly impaired neurological function (CPC 2–3) and 1 with severe disability (CPC 4). During ECLS we observed the following complications: bleeding (28%), AKI (28%), infections (28%), neurological complications as acute ischemic stroke or intracerebral hemorrhage (19%); no limb ischemia occurred. Conclusions ECLS provides cardiac and respiratory support and serves as a bridge to recovery or heart replacement therapies (LVAD, HT). Tertiary Shock Centers in a Regional Network assure optimal assistance for this vital support.
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Chugh, Radhika, and Wiley Harkens. "RF23 | PSAT301 Plasmapheresis and Extracorporeal Membrane Oxygenation (ECMO) for Treatment of Thyroid Storm with Multiorgan Failure." Journal of the Endocrine Society 6, Supplement_1 (November 1, 2022): A858—A859. http://dx.doi.org/10.1210/jendso/bvac150.1775.
Анотація:
Abstract Introduction Thyroid storm is a life-threatening condition with a high morbidity and mortality rate. It can lead to severe end organ damage including liver injury, which can preclude the use of thionamides. Therapeutic plasma exchange can be a lifesaving option for treatment of thyroid storm in such cases. Multiorgan failure can also necessitate the use of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Case Presentation A 34-year-old woman with a history of Graves’ disease, untreated for several years, presented to the emergency department with fatigue, palpitations, dyspnea, and edema which developed over 1 month. Labs showed suppressed thyroid stimulating hormone (TSH) with significantly elevated free T4 of 10.8 ng/dL (normal 0.89-1.76 ng/dL). She had evidence of atrial fibrillation and heart failure. She was started on treatment with propylthiouracil, propranolol, and hydrocortisone and then Lugol's iodine was added. However, she quickly deteriorated with worsening mentation, dyspnea, and hypotension. She progressed to multiorgan failure including significant liver injury likely due to ischemic hepatitis. Thus, thianomides could not be used any further. She was started on cholestyramine; hydrocortisone and Lugol's iodine were continued.An echocardiogram revealed global hypokinesis with a left ventricular ejection fraction of 20%. Beta blockers were discontinued due to hypotension. The cardiogenic shock worsened despite aggressive medical therapy requiring initiation of veno-arterial (V-A) ECMO. She also required CRRT due to renal failure.Plasmapheresis was initiated for treatment of thyroid storm and she received 4 treatments with normalization of free T4: 1.48 ng/dL and T3 levels: 3.4 ng/dL (normal 2.3-4.2 ng/dL). Her condition subsequently improved and she was decannulated from the ECMO device after 5 days. She was then able to receive definitive treatment with thyroidectomy 11 days following admission. The patient was discharged in improved condition after a 10-week hospital course. Discussion Thyroid storm is a rare complication of thyrotoxicosis with a mortality rate of 10-30%. Treatment classically involves inhibiting the synthesis, release, and peripheral conversion of thyroid hormone as well as supportive management. Major causes of mortality in thyroid storm, present in our patient, include cardiogenic shock, arrhythmia, and multiorgan failure. Cardiac and hepatic failure can preclude the use of beta blockers and thionamides, which may necessitate the use of extracorporeal treatments, such as plasmapheresis for clearance of high burden of circulating thyroid hormone; V-A ECMO and CRRT for end organ damage. These therapeutic measures were used in our patient and led to a favorable outcome. This case highlights the successful use of these extracorporeal treatments as a bridge to thyroidectomy when standard medical treatment is contraindicated or unsuccessful. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:42 p.m. - 12:47 p.m.
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Pressiat, Claire, Agathe Kudela, Quentin De Roux, Nihel Khoudour, Claire Alessandri, Hakim Haouache, Dominique Vodovar, et al. "Population Pharmacokinetics of Amikacin in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation." Pharmaceutics 14, no. 2 (January 26, 2022): 289. http://dx.doi.org/10.3390/pharmaceutics14020289.
Анотація:
Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support leads to complex pharmacokinetic alterations, whereas adequate drug dosing is paramount for efficacy and absence of toxicity in critically ill patients. Amikacin is a major antibiotic used in nosocomial sepsis, especially for these patients. We aimed to describe amikacin pharmacokinetics on V-A ECMO support and to determine relevant variables to improve its dosing. All critically ill patients requiring empirical antimicrobial therapy, including amikacin for nosocomial sepsis supported or not by V-A ECMO, were included in a prospective population pharmacokinetic study. This population pharmacokinetic analysis was built with a dedicated software, and Monte Carlo simulations were performed to identify doses achieving therapeutic plasma concentrations. Thirty-nine patients were included (control n = 15, V-A ECMO n = 24); 215 plasma assays were performed and used for the modeling process. Patients received 29 (24–33) and 32 (30–35) mg/kg of amikacin in control and ECMO groups, respectively. Data were best described by a two-compartment model with first-order elimination. Inter-individual variabilities were observed on clearance, central compartment volume (V1), and peripherical compartment volume (V2). Three significant covariates explained these variabilities: Kidney Disease Improving Global Outcomes (KDIGO) stage on amikacin clearance, total body weight on V1, and ECMO support on V2. Our simulations showed that the adequate dosage of amikacin was 40 mg/kg in KDIGO stage 0 patients, while 25 mg/kg in KDIGO stage 3 patients was relevant. V-A ECMO support had only a secondary impact on amikacin pharmacokinetics, as compared to acute kidney injury.
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Wiest, Clemens, Alois Philipp, Maik Foltan, Florian Geismann, Roland Schneckenpointer, Simon Baumgartner, Florian Sticht, et al. "Refractory circulatory failure in COVID-19 patients treated with veno-arterial ECMO a retrospective single-center experience." PLOS ONE 19, no. 4 (April 1, 2024): e0298342. http://dx.doi.org/10.1371/journal.pone.0298342.
Анотація:
Objective In this retrospective case series, survival rates in different indications for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and differential diagnoses of COVID-19 associated refractory circulatory failure are investigated. Methods Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO. All VA-ECMO’s were cannulated peripherally, using a femoro-femoral cannulation. Results At VA-ECMO initiation, median age was 57 years (IQR: 51–62), SOFA score 16 (IQR: 13–17) and norepinephrine dosing 0.53μg/kg/min (IQR: 0.35–0.87). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Indications for VA-ECMO support were pulmonary embolism (PE) (n = 5, survival 80%), right heart failure due to secondary pulmonary hypertension (n = 5, survival 20%), cardiac arrest (n = 4, survival 25%), acute heart failure (AHF) (n = 10, survival 40%) and refractory vasoplegia (n = 4, survival 0%). Among the patients with AHF, 4 patients suffered from COVID-19 associated heart failure (CovHF) (survival 100%) and 6 patients from sepsis associated heart failure (SHF) (survival 0%). Main Complications were acute kidney injury (AKI) 93%, renal replacement therapy was needed in 79%, intracranial hemorrhage occurred in 18%. Overall survival to hospital discharge was 39%. Conclusion Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decision making. A subgroup of patients suffers from acute heart failure due to inflammation, which has to be differentiated into septic or COVID-19 associated. Novel biomarkers are required to ensure reliable differentiation between these entities; a candidate might be soluble interleukin 2 receptor.
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Winiszewski, Hadrien, Pierre-Grégoire Guinot, Matthieu Schmidt, Guillaume Besch, Gael Piton, Andrea Perrotti, Roberto Lorusso, Antoine Kimmoun, and Gilles Capellier. "Optimizing PO2 during peripheral veno-arterial ECMO: a narrative review." Critical Care 26, no. 1 (July 26, 2022). http://dx.doi.org/10.1186/s13054-022-04102-0.
Анотація:
AbstractDuring refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (PPOSTO2) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this PPOSTO2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (FSO2). Because of the oxygenator’s performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO2) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting FSO2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of PPOSTO2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.
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Göbölös, Laszlo, Maurice Hogan, Vivek Kakar, Nuno Raposo, Stefan Sänger, Gopal Bhatnagar, and Woosup Michael Park. "Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO." Perfusion, March 26, 2021, 026765912110032. http://dx.doi.org/10.1177/02676591211003282.
Анотація:
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an established last line support for severe, acute cardiorespiratory failure. In the case of VA ECMO, peripheral cannulation via the femoral vessels is often advantageous when compared with the alternative central cannulation, and is associated with better clinical outcomes. One of the specific potential complications of peripheral femoral arterial cannulation for ECMO, however, is ipsilateral distal lower limb ischemia; a consideration especially when cannulating the vessel directly, as distal limb perfusion is invariably compromised by an occlusive effect of the arterial cannula within the femoral artery. The gold standard technique for lower limb reperfusion is a separate size 6–7 Fr cannula inserted proximally into the femoral artery, just below the insertion point of the ECMO return cannula, and connected directly to the ECMO circuit so that the blood flow is also directed distally to perfuse the entire limb. This functions well whether the ECMO cannula has been placed percutaneously or by surgical cut-down. Although proximal femoral arterial placement of the reperfusion cannula is the established and preferred technique, there are many technical challenges which may preclude its placement. Local haematoma or bleeding post ECMO insertion, peripheral vascular disease, constricted vasculature in severely shocked patients, or patient obesity are all common reasons why placement of the proximal reperfusion cannula may be difficult, or impossible. In such instances, our retrograde perfusion technique may maintain limb perfusion and may even be limb saving for patients on VA ECMO support.
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Pirompanich, Pattarin, Napakul Patiyakul, Kiattichai Daorattanachai, Boonlawat Homvises, and Pichaya Tantiyavarong. "Clinical characteristics and outcomes of adults with peripheral extracorporeal membrane oxygenation in a developing country: A single center 8-year retrospective study." Perfusion, December 16, 2020, 026765912098037. http://dx.doi.org/10.1177/0267659120980376.
Анотація:
Introduction: In our institute, we began using peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in 2010, and peripheral veno-venous (VV) ECMO in 2015. This study aimed to describe clinical characteristics and outcomes in those patients. Methods: We reviewed retrospective data of adults receiving peripheral ECMO from January 2010 to December 2017 and divided it into two groups for analysis: VA- and VV-ECMO. Results: There were 28 patients in the VA group and 12 in VV. For VA, the mean (SD) age was 58.5 (17.2) years. The most common indication was cardiac arrest (12 patients, 42.9%); 15 patients (53.6%) were on intra-aortic balloon pump concomitantly. In the VV cohort, the mean age was 53.3 (16.2) years. Eleven (91.7%) patients had acute respiratory distress syndrome as an indication. The mortality rate of VA-ECMO was 85.7%, and VV was 58.3%. Conclusion: The mortality rate in our ECMO center was considerably higher than that in the international registry report. Improved team education, rigid patient selection criteria, and a reimbursement protocol should lead to ameliorated outcomes. Trial Registration: TCTR20190120001. Registered January 19, 2019
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Kalampokas, Nikolaos, Nihat Firat Sipahi, Hug Aubin, Payam Akhyari, Georgi Petrov, Alexander Albert, Ralf Westenfeld, Artur Lichtenberg, and Diyar Saeed. "Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Does the Cannulation Technique Influence the Outcome?" Frontiers in Cardiovascular Medicine 8 (August 9, 2021). http://dx.doi.org/10.3389/fcvm.2021.658412.
Анотація:
Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be cannulated using either central (cannulation of aorta) or peripheral (cannulation of femoral or axillary artery) access. The ideal cannulation approach for postcardiotomy cardiogenic shock (PCS) is still unknown. The aim of this study is to compare the outcome of patients with PCS who were supported with central vs. peripheral cannulation.Methods: This is a single-center retrospective data analysis including all VA-ECMO implantations for PCS from January 2011 to December 2017. The central and peripheral approaches were compared in terms of patient characteristics, intensive care unit (ICU) stay, hospitalization length, adverse event rates, and overall survival.Results: Eighty-six patients met the inclusion criteria. Twenty-eight patients (33%) were cannulated using the central approach, and 58 patients (67%) were cannulated using the peripheral approach. Forty-three patients (50%) received VA-ECMO in the operating room and 43 patients (50%) received VA-ECMO in the ICU. Central VA-ECMO group had higher EuroSCORE II (p = 0.007), longer cross-clamp time (p = 0.054), higher rate of open chest after the procedure (p < 0.001), and higher mortality rate (p = 0.02). After propensity score matching, 20 patients in each group were reanalyzed. In the matched groups, no statistically significant differences were observed in the baseline characteristics between the two groups except for a higher rate of open chests in the central ECMO group (p = 0.02). However, no significant differences were observed in the outcome and complications between the groups.Conclusions: This study showed that in postcardiotomy patients requiring VA-ECMO support, similar complication rates and outcome were observed regardless of the cannulation strategy.
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Gobolos, Laszlo, Maurice Hogan, Vivek Kakar, Stefan Sanger, Nuno Raposo, GOPAL BHATNAGAR, and Woosup Park. "Abstract 16853: Retrograde Peripheral Limb Perfusion for Formidable Femoral Arterial Access in Veno-Arterial ECMO Treatment." Circulation 142, Suppl_3 (November 17, 2020). http://dx.doi.org/10.1161/circ.142.suppl_3.16853.
Анотація:
Introduction: VA ECMO has emerged to a well-established therapeutic method in severe acute heart failure. In the case of peripheral ECMO placement, especially applying direct arterial cannulation, the limb perfusion is often compromised by an occlusive effect of the cannula positioned in the femoral artery. The classical proximal femoral arterial reperfusion branch provides sufficient blood flow via a small auxiliary cannula, but in patients with severe peripheral arterial vasculopathy or with significant tissue depth resulting from obesity, the placement of a peripheral arterial perfusion loop may pose a technical challenge. Methods: In case of emerging peripheral ischemic symptoms at femoral VA ECMO placement, ultrasound scanning of the lower limb vessels is performed. In an uncomplicated vascular situation, antegrade distal perfusion can be established. If a significant vasculopathy is present in the proximal vessels, or any further hindrances, including extreme obesity, physically not allowing a subtle perfusion cannula placement resulting from the discrepancy between the tissue depth and cannula length, retrograde peripheral perfusion could be established via the dorsal pedal artery utilising the Seldinger method. An ultrasonographic guidance is essential; hence there is sometimes no backflow present on the inserted cannula in a critically ischemic limb. Following sufficient de-airing manoeuvres, the retrograde femoral flow can be safely established; NIRS confirms the successful reperfusion in a short timeframe. If the dorsal pedal artery is not sufficient for cannulation purposes, the postmalleolar posterior tibial artery segment or the anterior tibial artery through the similarly named muscle can be utilised for cannulation purposes. Results: Two patients showed a pre-reperfusion calf saturation of 29% and 38%, which has increased to 61% and 64% after re-establishing the distal flow within minutes, respectively. We have experienced no complications emerging during the application of the above method. Conclusions: In case of peripheral vascular disease or the body habitus does not allow safe installation of an antegrade flow device, our retrograde perfusion option can save the affected limb on VA ECMO therapy.
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Warnock, Brielle, Gina Maria Lafferty, Abdelaziz Farhat, Cameron Colgate, Archana Dhar, and Brian Gray. "Peripheral Veno-Arterial-Extracorporeal Membrane Oxygenation for Refractory Septic Shock in Children: A Multicenter Review." Journal of Intensive Care Medicine, October 29, 2023. http://dx.doi.org/10.1177/08850666231193357.
Анотація:
Background Extracorporeal membrane oxygenation (ECMO) is utilized as a rescue therapy in the management of pediatric patients with refractory septic shock. Multiple studies support the use of a central cannulation strategy in these patients. This study aimed to assess the survival of and identify mortality risk factors in pediatric patients supported with peripheral veno-arterial (VA) ECMO in the setting of septic shock. Methods We retrospectively reviewed and compared clinical characteristics of 40 pediatric patients supported with peripheral VA ECMO for refractory septic shock, at two tertiary care children's hospitals from 2006 to 2020. Our hypothesis was that peripheral VA ECMO is effective in supporting cardiac function and improving tissue oxygenation in most pediatric patients with refractory septic shock. Results The overall rate of survival to discharge was 52.5%, comparable to previously reported survival for pediatric sepsis on ECMO. With the exclusion of patients with an oncologic process, the survival rate rose to 62.5%. There was a statistically significant difference in mean pump flow rates within 2 hours of initiation of ECMO between survivors and non-survivors (98 mL/kg/min vs 76 mL/kg/min, P = .050). There was no significant difference between pre-ECMO vasoactive inotropic score (VIS) in survivors and non-survivors. A faster decrease in VIS in the first 24 hours was associated with lower mortality. Conclusions From this large case series, we conclude that peripheral VA ECMO is a safe and effective modality to support pediatric patients with refractory septic shock, provided there is establishment of high ECMO pump flows in the first few hours after cannulation and improvement in the VIS.
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Ng, Pauline Yeung, Sin Kwan Tammy Ma, April Ip, Shu Fang, Alfred Sai Kuen Wong, Chun Wai Ngai, Wai Ming Chan, and Wai Ching Sin. "Abstract 10117: Reactivity Of Myocardial Contractility To Afterload Effects During Peripheral Veno-arterial Extracorporeal Membrane Oxygenation." Circulation 144, Suppl_1 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_1.10117.
Анотація:
Introduction: Peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) poses increased afterload to the injured heart. The reactivity of myocardial contractility to ECMO blood flow during various phases of acute myocardial dysfunction has not been examined. Hypothesis: We hypothesized that myocardial contractility is more reactive to the afterload effects of peripheral V-A ECMO during the acute stage of myocardial dysfunction. Methods: Adult patients who were supported by peripheral V-A ECMO between April 2019 and October 2020 were recruited. Serial hemodynamic and cardiac performance parameters were measured by TTE within 48 hours after initiation of V-A ECMO (“acute phase”) and upon weaning (“delayed phase”). Measurements were obtained at 100%, 120%, and 50% of ECMO target blood flow. Results: A total of 30 patients were included, 22 (71%) were male, and the mean±SD age was 54±13 years. The main indications of ECMO were myocardial infarction (19 patients, 63%) and myocarditis (5, 17%). TTE was performed on a median of day 1 (1-1) (n=30, “acute phase”) and day 4.5 (3-6) (n=24, “delayed phase”) after initiation of ECMO. Left ventricular contractility was reactive to afterload effects from V-A ECMO in both the acute and delayed phases, with an improvement in LVEF during ECMO flow reduction from 21.5 to 30.9% (p<0.001) and 34.5 to 41.7% (p=0.002), respectively. The change in LVEF was similar in the acute phase compared with the delayed phase when considering the whole cohort [median (IQR) change in LVEF: 8.88 (5.26 - 13.7)% vs 6.12 (0.64 - 15.60)%, p=0.38]. Of the 24 patients who had a TTE during the delayed phase, 16 (66.7%) had myocardial recovery and were weanable from ECMO support. The reactivity of LVEF to ECMO blood flow was similar in the patients who were weanable compared with patients who were not weanable [median (IQR) change in LVEF: 10.21 (2.61 - 16.21)% vs 3.20 (-2.13 - 6.79)%, p=0.14]. Conclusions: In conclusion, we demonstrated that the reactivity of left ventricular contractility to afterload effects of V-A ECMO was not significantly different at different stages of acute myocardial dysfunction. Future studies should examine the predictive value and clinical utility of these echocardiographic measurements in patients on V-A ECMO.
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Tantway, Tarek M., Amr A. Arafat, Monirah A. Albabtain, Makhlouf Belghith, Ahmed A. Osman, Mohamed A. Aboughanima, Muhammad T. Abdullatif, Youssef A. Elshoura, and Mohammed M. AlBarak. "Sepsis in postcardiotomy cardiogenic shock patients supported with veno-arterial extracorporeal membrane oxygenation." International Journal of Artificial Organs, February 6, 2023, 039139882311529. http://dx.doi.org/10.1177/03913988231152978.
Анотація:
Background: Sepsis could affect the outcomes of patients with postcardiotomy cardiogenic shock supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to characterize sepsis patients with ECMO support for postcardiotomy cardiogenic shock and assess its predictors and effect on patients’ outcomes. Methods: This retrospective study included 103 patients with ECMO for postcardiotomy cardiogenic shock from 2009 to 2020. Patients were divided according to the occurrence and timing of sepsis into three groups. Group 1 included patients with no sepsis ( n = 67), Group 2 included patients with ECMO-related sepsis ( n = 10), and Group 3 included patients with non-ECMO-related sepsis ( n = 26). Results: Lactate level before ECMO was highest in the ECMO-associated sepsis group (Group 1 and 2 p = 0.003 and Group 2 and 3 p = 0.003). Dialysis and gastrointestinal bleeding were highest in ECMO-associated sepsis ( p = 0.03 and 0.04, respectively). Blood transfusion was higher in ECMO-associated sepsis than in patients with no sepsis ( p = 0.01). Mortality was nonsignificantly higher in patients with ECMO-associated sepsis. High BMI (OR: 1.11; p = 0.004), preoperative dialysis (OR: 7.35; p = 0.02), preoperative IABP (OR: 9.9.61; p = 0.01) and CABG (OR: 6.29; p = 0.01) were significantly associated with sepsis. Older age (OR: 1.08; p = 0.004), lower BSA (OR: 0.004; p = 0.003), peripheral cannulation (OR: 29.82; p = 0.03), and high pre ECMO lactate level (OR: 1.24; p = 0.001) were associated with increased mortality. Sepsis did not predict mortality (OR: 1.83; p = 0.21). Conclusions: Sepsis is a dreaded complication in patients with postcardiotomy cardiogenic shock, especially ECMO-associated sepsis. Preoperative risk factors could predict postoperative sepsis in ECMO patients.
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Ng, Pauline Yeung, Tammy Sin Kwan Ma, April Ip, Shu Fang, Andy Chak Cheung Li, Alfred Sai Kuen Wong, Chun Wai Ngai, Wai Ming Chan, and Wai Ching Sin. "Effects of varying blood flow rate during peripheral veno-arterial extracorporeal membrane oxygen (V-A ECMO) on left ventricular function measured by two-dimensional strain." Frontiers in Cardiovascular Medicine 10 (April 12, 2023). http://dx.doi.org/10.3389/fcvm.2023.1147783.
Анотація:
BackgroundWe evaluated the effects of varying blood flow rate during peripheral veno-arterial extracorporeal membrane oxygen (V-A ECMO) on left ventricular function measured by two-dimensional strain.MethodsAdult patients who were supported by peripheral V-A ECMO were recruited. Serial hemodynamic and cardiac performance parameters were measured by transthoracic echocardiogram within the first 48 h after implementation of V-A ECMO. Measurements at 100%, 120%, and 50% of target blood flow (TBF) were compared.ResultsA total of 54 patients were included and the main indications for V-A ECMO were myocardial infarction [32 (59.3%)] and myocarditis [6 (11.1%)]. With extracorporeal blood flow at 50% compared with 100% TBF, the mean arterial pressure was lower [66 ± 19 vs. 75 ± 18 mmHg, p < 0.001], stroke volume was greater [23 (12–34) vs. 15 (8–26) ml, p < 0.001], and cardiac index was higher [1.2 (0.7–1.7) vs. 0.8 (0.5–1.3) L/min/m2, p < 0.001]. Left ventricular contractile function measured by global longitudinal strain improved at 50% compared with 100% TBF [−2.8 (−7.6- −0.1) vs. −1.2 (−5.2–0) %, p < 0.001]. Similarly, left ventricular ejection fraction increased [24.4 (15.8–35.5) vs. 16.7 (10.0–28.5) %, p < 0.001] and left ventricular outflow tract velocity time integral increased [7.7 (3.8–11.4) vs. 4.8 (2.5–8.5) cm, p < 0.001]. Adding echocardiographic parameters of left ventricular systolic function to the Survival After Veno-arterial ECMO (SAVE) score had better discriminatory value in predicting eventual hospital mortality (AUROC 0.69, 95% CI 0.55–0.84, p = 0.008) and successful weaning from V-A ECMO (AUROC 0.68, 95% CI 0.53–0.83, p = 0.017).ConclusionIn the initial period of V-A ECMO support, measures of left ventricular function including left ventricular ejection fraction and global longitudinal strain were inversely related to ECMO blood flow rate. Understanding the heart-ECMO interaction is vital to interpretation of echocardiographic measures of the left ventricle while on ECMO.
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"Hospital outcomes after emergent peripheral veno-arterial extracorporeal membrane oxygenation in adult patients presenting with cardiogenic shock." Signa Vitae, 2021. http://dx.doi.org/10.22514/sv.2021.118.
Анотація:
Background: Emergent peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used frequently to support patients with refractory cardiogenic shock with variable rates of complications. We retrospectively analyzed adult patients who received peripheral VA-ECMO support between 2015 and 2019 at our tertiary care hospital. Results: Sixty five patients with a mean age of 37.9 ± 14.9 years, mostly males (70.8%), were supported with femoral VA-ECMO with a median duration of 8 (IQR: 3–40) days. Hospital mortality occurred in 29 (44.6%) patients. Complications included acute kidney injury (AKI) in 39 (60%), acute cerebral strokes in 13 (20%), gastrointestinal bleeding in 14 (21.5%) and acute limb ischemia in 21 (32.3%) patients. Non-survivors had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores and significantly increased rates of acute kidney injury, renal replacement therapy, ischemic cerebral strokes, cannulation site exploration for bleeding, atrial fibrillation and anticoagulation discontinuation. Multivariable regression analysis revealed significant Odds Ratios (OR), 95% Confidence Intervals (CI) of hospital mortality with: increasing SOFA scores after 48 hours (2.15, 1.441–3.214, p < 0.001), atrial fibrillation (11.351, 1.354–83.222, p = 0.025) and hyperlactatemia (2.74, 1.448–6.719, p = 0.016). Conclusion: High mortality and frequent morbidities due to emergent peripheral VA-ECMO should be considered before initiation for cardiogenic shock. According to our results, increasing trend of SOFA scores, atrial fibrillation and progressive hyperlactatemia are independent predictors of hospital mortality of peripheral VA-ECMO.
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Lucia, Mazzoni, Azmoun Alexandre, Ramadan Ramzi, Ghostine Saïd, Kloeckner Martin, Brenot Philippe, Fradi Mohamed, Nottin Rémi, and Deleuze Philippe. "Exclusive percutaneous peripheral veno-arterial ECMO with distal reperfusion of homolateral limb." Journal of Cardiothoracic Surgery 10, S1 (December 2015). http://dx.doi.org/10.1186/1749-8090-10-s1-a260.
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Alonso Fernandez De Gatta, M., S. Merchan Gomez, A. Diego Nieto, M. Gonzalez Cebrian, F. Martin Herrero, E. Alzola, I. Toranzo Nieto, A. Barrio Rodriguez, M. Lopez Serna, and P. L. Sanchez Fernandez. "P1714Short-term survival prognostic factors in patients supported with veno-arterial extracorporeal membrane oxygenator." European Heart Journal 40, Supplement_1 (October 1, 2019). http://dx.doi.org/10.1093/eurheartj/ehz748.0469.
Анотація:
Abstract Introduction Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides cardiopulmonary support in different conditions with circulatory compromise, assuming high complication and mortality rates. Purpose Identify predictive factors of short-term survival. Methods Retrospective study including all VA-ECMO implants in a referral hospital. Univariate and multivariate analysis of factors related to discharge survival. Results 85 VA-ECMO were implanted from 2013 to Jan-2019 (table). Survival at discharge was 42.4%. Deaths were due to multiorgan dysfunction syndrome (44.9%), anoxic encephalopathy (18.4%) and bleeding (10.2%). A lower post-implantation LVEF (at weaning or later) was associated with a decrease in survival (p0.002), as well as higher lactate (p<0.001) and LDH (p0.019) or presence of preimplantation cardiac arrest (p<0.001) and its duration (p0.049). The appearance of peripheral ischemia, ischemic/hemorrhagic stroke, bleeding, infections and need for renal replacement therapy were associated with shorter survival (p<0.001 all variables). At the multivariate analysis, a better post-implant LVEF was a protective factor (HR 0.9, IC95% 0.83–0.97, p0,002) and higher pre-implant lactate level was independent predictor of mortality (HR 1.3, IC95% 1.1–1.98, p=0,019). ROC analysis revealed the best cut-off for predicting survival at hospital discharge of postimplant LVEF (33,5%, Sen 86%, Spe 70%, AUC=0.76) and lactate (8.5 mmol/L, Sen 88%, Spe 45%, AUC=0.706) (Figure). Patients' characteristics Baseline characteristics (n=85) Periimplantation characteristics Complications (n,%) Age (years) (mean ± SD) 61.2±10 Peripheral cannulation (n, %) 79 (92.9%) Vascular 16 (18.8%) Male (n, %) 64 (75.3%) Percutaneous implant (n, %) 58 (68.2%) Peripheral ischemia 12 (14.%) Situation at the admission Intraaortic balloon pump (n, %) 40 (47.1%) Critical care patient infections 38 (47.7%) Bridge to recovery (n, %) 73 (85.9%) Noradrenalin (n, %) 71 (83.5%) Minor or mayor bleeding 39 (45.9%) Indication (n, %) Dobutamine (n, %) 71 (83.5%) Need for transfusion 60 (70.6%) Cardiogenic shock 38 (44.7%) Adrenaline (n, %) 26 (20.6%) Ischemic stroke 4 (4.7%) Cardiac arrest 10 (11.8%) Blood test (mean ± SD) Hemorrhagic stroke 3 (3,5%) Electrical storm 7 (8.2%) pH 7.26±0,2 Renal replacement therapy 16 (18.8%) High-risk percutaneous intervention 8 (8.2%) Lactate (mmol/L) 6.56±4,4 Critical patient polyneuropathy 16 (18.8%) Postcardiotomy shock 21 (24.7%) Creatinine (mg/dl) 1.58±1,5 Tracheostomy 14 (16.5%) Others 2 (2.4%) Bilirrubin (mg/dl) 1.1±1 ECMO circuit 7 (8.2%) Preimplant cardiac arrest (n, %) 45 (52.9%) LDH (U/L) 959±67 Cardiac arrest duration (min) (n, %) 29.6±23 Time ECMO support (days) (mean ± SD) 4.84±4 LVEF (%) (mean ± SD) 29.9±17.5 ECMO-CPR (n, %) 19 (22.4%) LVEF weaning (%) (mean+SD) 40.2±15.9 RV dysfunction (n, %) 41 (48.2%) ROC curves for survival at discharge Conclusion VA-ECMO is an effective tool for hemodynamic support in circulatory compromise cases but it has high morbi-mortality. The higher lactate and LDH level, cardiac arrest prior to implantation and the appearance of complications decrease survival significantly. Lactate at implantation and post-implantation LVEF (at weaning or later) were independent predictors of survival.
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Toda, Koichi, Junya Ako, Atsushi Hirayama, Koichiro Kinugawa, Yoshio Kobayashi, Minoru Ono, Takashi Nishimura, et al. "Outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation With Percutaneous Left Ventricular Unloading in Fulminant Myocarditis." ASAIO Journal, November 23, 2023. http://dx.doi.org/10.1097/mat.0000000000002104.
Анотація:
Fulminant myocarditis requiring peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has a high mortality rate. We investigated clinical outcomes of combined use of VA-ECMO and percutaneous left ventricular assist device (VAD) (Impella) for fulminant myocarditis in 104 consecutive patients enrolled in the Japan Registry for Percutaneous VAD (J-pVAD) between October 2017 and January 2020. Patients were followed until hospital discharge and predictors of survival were analyzed with a Cox proportional hazards model. The median support duration of combined use of VA-ECMO and Impella (ECMO/Impella) was 6 days, and the median left ventricular ejection fraction improved from 15% to 52% during support (p < 0.0001). Overall, 66 patients (63%) survived to discharge. Multivariate analysis revealed ECMO/Impella support at a transplant center as an independent predictor of survival (p = 0.0231). Patients treated at transplant centers had better 60 days survival rates when compared to nontransplant centers (83% vs. 55%, p = 0.005). However, baseline characteristics and treatment strategies differed between the two groups. This real-world national registry database suggested the difference in survival after ECMO/Impella support for fulminant myocarditis between transplant and nontransplant centers, which may indicate hospital variations regarding patient management, although further controlled studies are needed.
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Lee, S., E. Kang, M. Heo, and C. Ahn. "Real-world clinical outcome related to veno-arterial extracorporeal membranous oxygenator: a single-center experience." European Heart Journal: Acute Cardiovascular Care 13, Supplement_1 (April 2024). http://dx.doi.org/10.1093/ehjacc/zuae036.153.
Анотація:
Abstract Funding Acknowledgements None. Background Veno-arterial extracorporeal membranous oxygenator (VA-ECMO) is one of the most powerful devices that rapidly restore sufficient organ perfusion in patients with cardiogenic shock. Despite abundant experiences of successful resuscitation with VA-ECMO, evidences for clinical benefit of VA-ECMO are still lacking. Purpose We summarised clinical outcomes related to VA-ECMO and investigated predictors regarding survival at discharge. Methods Patients who treated with peripheral VA-ECMO between 2006 and 2022 were included from a Hospital in South Korea. Eligible patients were analysed in stratification with ECMO initiation year (year 2006–2010, year 2011–2016, and year 2017–2022). Survival status at discharge were investigated. Results Among total of 693 patients included, 223 (32.2%) were survived at discharge. Survivors had stayed in hospital for median 28 (19–52) days. The overall volume of ECMO initiation (86 runs vs. 250 runs vs. 357 runs) and the rate of extracorporeal CPR (3.5% vs. 18.4% vs. 38.1%) have increased over time. The median duration of VA-ECMO treatment has increased over time (52.6 hours vs. 63.6 hours vs. 85.8 hours). The serum lactate test has been performed more frequently over time (15.1% vs. 79.6% vs. 99.2%). Among 470 patients who died in the index hospitalization, 154 (32.8%) patients died in the first 24 hours after initiation of VA-ECMO. In a multivariate regression model, age over 70 (OR, 0.54; 95% CI, 0.32–0.89), extracorporeal CPR (OR, 0.42; 95% CI, 0.24–0.71), and lactate level ≥8.0 mmol/L (OR, 0.24; 95% CI, 0.15–0.37) were associated with unfavorable outcome while hemoglobin was a predictor of favorable clinical outcome (OR, 1.16; 95% CI, 1.07–1.25). Conclusion The volume of VA-ECMO has increased and clinical severity has also become higher than before. The rate of survival at discharge after VA-ECMO treatment remains stable; however, the rate of patients who died in the first 24 hours is still high. Age, extracorporeal CPR, hemoglobin and lactate levels were predictors of clinical outcome after VA-ECMO treatment.
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Gangahanumaiah, Shivanand, Michael Zhu, Robyn Summerhayes, and Silvana F. Marasco. "Spinal cord infarction and peripheral extracorporeal membrane oxygenation: a case series." European Heart Journal - Case Reports 5, no. 12 (December 1, 2021). http://dx.doi.org/10.1093/ehjcr/ytab488.
Анотація:
Abstract Background Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is increasingly utilized in patients with cardiogenic shock due to improved technology and outcomes. Peripheral VA ECMO offers several advantages over central ECMO and is becoming increasingly popular. However, when configured via the femoral vessels, retrograde flow to the descending aorta and arch of aorta competes with antegrade ventricular output and can be associated with a watershed phenomenon and increased risk of neurologic and visceral injury. Case summary In this case series, we report three patients who were supported with peripheral VA ECMO for cardiogenic shock. All three were successfully weaned from peripheral VA ECMO; however, they had developed bilateral lower limb paralysis. Magnetic resonance imaging revealed spinal cord infarction in all three patients. All patients subsequently succumbed to multiorgan failure and did not survive to hospital discharge. Discussion The use of mechanical circulatory support, in particular, peripheral ECMO, has escalated with advances in technology, better understanding of cardiac physiology and improving outcomes. Spinal cord infarction is a rare but serious complication of peripheral VA ECMO support with only a few case reports published. Further studies are needed to identify the exact cause and prevention of this rare but often terminal complication. Through this series of three patients supported on peripheral VA ECMO complicated by spinal cord infarction, we review previously published reports, analyse possible mechanisms, and propose alternate management strategies to be considered in patients at risk.
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Ehrenberger, Réka, Balázs T. Németh, Péter Kulyassa, Gábor A. Fülöp, Dávid Becker, Boldizsár Kiss, Endre Zima, Béla Merkely, and István F. Édes. "Acute coronary syndrome associated cardiogenic shock in the catheterization laboratory: peripheral veno-arterial extracorporeal membrane oxygenator management and recommendations." Frontiers in Medicine 10 (November 7, 2023). http://dx.doi.org/10.3389/fmed.2023.1277504.
Анотація:
Cardiogenic shock (CS) in acute coronary syndrome (ACS) is a critical disease with high mortality rates requiring complex treatment to maximize patient survival chances. Emergent coronary revascularization along with circulatory support are keys to saving lives. Mechanical circulatory support may be instigated in severe, yet still reversible instances. Of these, the peripheral veno-arterial extracorporeal membrane oxygenator (pVA-ECMO) is the most widely used system for both circulatory and respiratory support. The aim of our work is to provide a review of our current understanding of the pVA-ECMO when used in the catheterization laboratory in a CS ACS setting. We detail the workings of a Shock Team: pVA-ECMO specifics, circumstances, and timing of implantations and discuss possible complications. We place emphasis on how to select the appropriate patients for potential pVA-ECMO support and what characteristics and parameters need to be assessed. A detailed, stepwise implantation algorithm indicating crucial steps is also featured for practitioners in the catheter laboratory. To provide an overall aspect of pVA-ECMO use in CS ACS we further gave pointers including relevant human resource, infrastructure, and consumables management to build an effective Shock Team to treat CS ACS via the pVA-ECMO method.
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Au, Shek-yin, Ka-man Fong, Chun-Fung Sunny Tsang, Ka-Chun Alan Chan, Chi Yuen Wong, Wing-yiu George Ng, and Kang Yin Michael Lee. "Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock." Perfusion, July 28, 2021, 026765912110339. http://dx.doi.org/10.1177/02676591211033947.
Анотація:
Introduction: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. Methods: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. Results: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. Conclusions: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.
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Zhang, Yan, Ming Luo, Bo Wang, Zhen Qin, and Ronghua Zhou. "Perioperative, protective use of extracorporeal membrane oxygenation in complex thoracic surgery." Perfusion, April 28, 2021, 026765912110110. http://dx.doi.org/10.1177/02676591211011044.
Анотація:
Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients undergoing complex thoracic surgical procedures. However, studies reporting the clinical outcomes of these patients are limited to case reports, without real consensus. Our aim was to evaluate the perioperative use of ECMO as respiratory and/or circulatory support in thoracic surgery: indications, benefits, and perioperative management. Methods: Between May 2013 and December 2018, we reviewed the clinical data of 15 patients (11 males and 4 females; mean age: 47 years old; range, 25–73 years) undergoing ECMO-assisted thoracic surgery in our hospital. Results: Of the 15 patients, 10 cases received peripheral veno-arterial (VA) ECMO and five cases received veno-venous (VV) ECMO. Indications for ECMO were pulmonary transplantation with hard-to-maintain oxygenation (n = 5), traumatic main bronchial rupture (n = 2), traumatic lung injury (n = 1), airway tumor leading to severe airway stenosis (n = 2), huge thoracic mass infiltrated vena cava (n = 5). The ECMO duration was 1–51 hours. All patients were successfully extubated and weaned from ECMO postoperatively. The main complications were hemorrhage (26.7%), infection (33.3%), acute hepatic dysfunction (33.3%), and venous thrombosis (26.7%). There was only one hospital death and postoperative one-year survival rate was 86%. Conclusion: Our experience indicates that ECMO is a feasible method for complex trachea-bronchial surgery, huge thoracic mass excision and lung transplantation, and the ECMO-related risks may be justified. With further accumulation of experience with ECMO, a more sophisticated protocol for management of critical airway or heart failure problems in thoracic surgeries can be derived.
49
Hussain, S., N. Zero, T. Al-Saadi, M. Asghar, N. Glowacki, A. Andrade, C. Sciamanna, et al. "Cerebrovascular accidents in patients supported with veno-arterial extra-corporeal membrane oxygenation- is duration of support important?" European Heart Journal 42, Supplement_1 (October 1, 2021). http://dx.doi.org/10.1093/eurheartj/ehab724.2268.
Анотація:
Abstract Purpose of study Veno-Arterial Extra-corporeal Membrane Oxygenation (VA-ECMO) is indicated for refractory cardiac and/or respiratory failure. Adverse events remain considerable despite best practices. We specifically aimed to understand risk factors associated with cerebrovascular accidents (CVA) in patients who underwent VA-ECMO support. Methods We retrospectively assessed all VA-ECMO patients from 2007 to 2019 at our institution. We identified those who experienced a CVA while supported by VA-ECMO. Patients with the primary event (CVA) were matched to controls (no CVA) based on age and sex. Comparisons were made between groups using McNemar's, Mantel-Haenszel, and Wilcoxon Signed-Rank tests where appropriate. Results Of the 278 VA-ECMO patients in the registry, 32 patients who experienced a CVA were identified; 24 (8.6%) ischemic and 8 (2.9%) hemorrhagic. Median age was 59.5 years (inter-quartile range: 49–65 years) and 75% of patients were males. Hypertension, diabetes, CAD and CHF were common co-morbidities (Table 1). Cardiogenic shock was the most common indication for VA-ECMO support in both cohorts, 75% in cases and 71.9% in controls. Cannulation strategies were identified as central or peripheral. There was a significant association of duration of VA-ECMO support with incidence of CVA, with a p-value of 0.03. Regression analysis showed a trend of increased risk of CVA by 4% for each additional day on VA-ECMO, however, this was not statistically significant (Odds ratio: 1.04; confidence interval 1.00–1.08). Most common outcome was death followed by decannulation to recovery and bridge to LVAD. Conclusion Ischemic and hemorrhagic CVAs are not uncommon during VA-ECMO support. Our case control study shows an association of duration of VA-ECMO support with incidence of CVA. This underscores the importance of timely assessment and weaning or bridging of VA-ECMO patients to their next management step. Funding Acknowledgement Type of funding sources: None.
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Prakash, PVS, Selvakumar R, Mr Shahenshah, Sanjay OP, Varun Shetty, Julius Punnen, and Devi Prasad Shetty. "Retrospective Analysis of ECMO for Acute Fulminant Viral Myocarditis." RGUHS Journal of Allied Health Sciences 2, no. 1 (2022). http://dx.doi.org/10.26463/rjahs.2_1_4.
Анотація:
Background The inflammation or degeneration of the heart muscle myocarditis may be fatal. This disease often goes undetected. It may also disguise itself as ischemic valvular or hypertensive heart disease. Here we report eight cases of acute fulminant viral myocarditis suffering from low cardiac output ARDS Acute respiratory distress syndrome formation and successfully treated with ECMO Extra corporeal membrane oxygenation.Methodology All the cases were admitted in the emergency coronary care unit with severe respiratory distress poor hemodynamics and ECHO examination revealed low Left ventricle Ejection Fraction LVEF15-20. Veno - Arterial ECMO was initiated with femoro-femoral cannulation with distal limb perfusion. On ECMO support the hemodynamics were stabilized with no inotropic support. The heart and lungs were given adequate rest time for recovery by maintaining total cardiac output on ECMO. The average ECMO support was 84.2 plusmn 4 hours. Maquet Quadrox PLS Sorin Dideco ECMO oxygenators with rotaflow centrifugal pump were used. Delta pressure pre-pump pressures were continuously monitored.Results Out of the eight cases put on VA ECMO for viral myocarditis seven were successfully weaned off and were discharged success rate of 87.5. Soon after the initiation of ECMO the arterial saturation reached the normal levels. The serum lactate levels which were high gt6 mmolL prior to initiation of ECMO remarkably came down to lt2 mmolL after 24 hours. Seven patients were weaned off and decannulated in the operating room. One patient required LV decompression by Balloon Atrial Septostomy in the Hybrid OR and was successfully weaned off after 48 hours. One patient succumbed due to continuous low cardiac output which was irreversible with full blown septicemia and was not responding to ECMO and medications.Conclusion Peripheral VA-ECMO support is very effective in optimizing myocardial recovery for the treatment of refractory acute fulminant viral myocarditis when maximal conventional supports are ineffective.