Arterial Extracorporeal Membrane Oxygenation Research Articles

Pulsatile Right Ventricle to Pulmonary Artery Extracorporeal Membrane Oxygenation in a Pigs

Background: We investigated the impact of right ventricle to pulmonary artery extracorporeal membrane oxygenation in acute respiratory dysfunction with or without pulsatile flow. Methods: We used bronchoalveolar lavage with intrapulmonary administration of warm saline to establish a severe acute respiratory distress syndrome model (ratio of partial pressure of oxygen in arterial blood to the fraction of inspiratory oxygen concentration ratio <200) in eight piglets (mean body weight: 8.45±1.24 kg). The piglets were categorized into the pulsatile (N=4) and non-pulsatile extracorporeal membrane oxygenation groups (N=4). We started right ventricle to pulmonary artery extracorporeal membrane oxygenation with a 60 mL/kg/min flow to support the animals for 6 hours. We monitored hemodynamic data and blood gas levels for assessing base excess, and performed arterial blood sampling and electrocardiogram. Interleukin-6 and endotherlin-1 concentrations in blood plasma were evaluated before and after right ventricle to pulmonary artery extracorporeal membrane oxygenation. We compared the lung wet/dry weight ratio as a measure of pulmonary edema and collected lung tissue samples for the pathologically evaluating pneumocytes before and after right ventricle to pulmonary artery extracorporeal membrane oxygenation. Results: We maintained stable hemodynamics and extracorporeal membrane oxygenation flow above an arterial oxygen saturation of 85% in both groups. Pneumocyte evaluation showed clearly less pulmonary edema, pulmonary fibrosis, and inflammation. Interleukin-6 concentration was less in the pulsatile group than in the non-pulsatile group. Conclusions: Pulsatile right ventricle to pulmonary artery extracorporeal membrane oxygenation was less vasoconstrictive and maintained more effective oxygenated pulmonary flow. It ameliorates pulmonary circulation and facilitates recovery from acute respiratory failure.

A Retrospective Cohort Analysis of Analgosedation Requirements in COVID-19 Compared to Non-COVID-19 Extracorporeal Membrane Oxygenation Patients.

Reports have described increased sedation requirements in patients with acute respiratory distress syndrome (ARDS) while on extracorporeal membrane oxygenation (ECMO) and for intubated COVID-19 patients. Thus, the objective of this study was to assess the analgosedation requirements of COVID-19 patients receiving ECMO compared to non-COVID-19 ECMO patients. This retrospective, observational cohort study included adult patients with ARDS requiring venovenous or venopulmonary arterial ECMO admitted to a single intensive care unit from January 2017 to December 2021. Patients were categorized as COVID-19 ECMO or non-COVID-19 ECMO. The primary outcome was median daily dosing of parenteral analgosedative medications. Pertinent secondary outcomes included incidence of extubation or tracheostomy and change in sedation following tracheostomy or addition of oral agents. A total of 109 patients were evaluated; 63 COVID-19 ECMO patients and 46 non-COVID ECMO patients. The primary outcome was statistically higher in the COVID-19 compared to non-COVID-19 patients for propofol (4131.0 mg vs 2704.8 mg, P < .001), dexmedetomidine (1581.4 mcg vs 1081.3 mcg, P = .016), and parenteral morphine equivalents ([PME], 209.3 mg vs 154.1 mg, P = .027), but only propofol remained significant after adjustment for weight (31.1 mcg/kg/day vs 37.7 mcg/kg/day, P = .014). COVID-19 was significantly associated with increased propofol and PME requirements after adjustment for confounders on linear regression analysis. COVID-19 patients had more days with non-zero dose for propofol (8 days vs 7 days), dexmedetomidine (13 days vs 8.5 days), and PME (17 days vs 8.5 days). The only interventions that were associated with reductions in propofol dose were tracheostomy and antipsychotics. COVID-19 patients on ECMO had significantly longer durations and higher doses of propofol, dexmedetomidine, and parenteral opioids over the first 28 days of cannulation. The only interventions that were associated with statistical reductions in propofol were antipsychotics and tracheostomy.

VENTRICULAR ARRHYTHMIAS IN A UNEXPECTED CARDIAC MAGNETIC RESONANCE

Abstract Background Electrical storm in a widespread inflammation of the myocardium represent a very challenge condition and recognizes a broad spectrum of etiology. Case Presentation A 59–year–old man, without significant prior medical history, came to our attention because, following an emergent hernioplasty procedure, he displayed anterior ST–segment elevation and elevated troponin levels (150.000 ng/L). An echocardiogram revealed an estimated left ventricular ejection fraction (EF) of 39% with anterior hypokinesia. Coronary angiography showed no abnormalities. Cardiac magnetic resonance imaging demonstrated ring–like edema and ring–like late gadolinium enhancement in the left ventricle on T2–weighted and PSIR sequences, with no involvement of the right ventricle. Additionally, there was an increase in extracellular volume. Despite several laboratory tests to investigate infectious or autoimmune causes, the etiology remained inconclusive. To further explore the cause, an endomyocardial biopsy was performed. However, the patient experienced an unstable electrical storm three days later. Management Recurrent ventricular tachycardia (VT) was initially treated with esmolol, amiodarone, and procainamide, but with limited success. Due to VT–induced hemodynamic instability, the patient was sedated with propofol and intubated. Endomyocardial biopsy (EMB) confirmed lymphocytic myocarditis. In light of the hemodynamic instability and refractory electrical storm, the patient was promptly cannulated for veno–arterial extracorporeal membrane oxygenation (VA–ECMO) and started on methylprednisolone. Although there was an apparent resolution of VT, the patient experienced new episodes, necessitating percutaneous stellate ganglion block and an upgraded treatment plan that included mycophenolate mofetil. Given the high burden of arrhythmias, severe ventricular dysfunction, and the lack of response to medications, the patient is now awaiting cardiac transplantation. Conclusion Transmural edema and ring–like late gadolinium enhancement (LGE) in the early phase are predictors of a poor prognosis. In cases of hemodynamic deterioration and refractory electrical storms, it is crucial to promptly initiate mechanical support. Cardiac transplantation remains the sole treatment option for individuals who do not respond to antiarrhythmic and immunosuppressive drugs.

Empowering Little Fighters: Post-Cardiotomy Pediatric ECMO and the Journey to Recovery.

Extra Corporeal Membrane Oxygenation (ECMO) has long been used for cardiorespiratory support in the immediate post-paediatric cardiac surgery period with a 2-3% success as per the ELSO registry. Success in recovery depends upon the optimal delivery of critical care to paediatric patients and a comprehensive healthcare team. The survival benefit of children placed on central veno arterial (VA) ECMO following elective cardiac surgeries for congenital heart disease (n = 672) was studied in a cohort of 29 (4.3%) cases from the period of Jan 2018 to Dec 2022 in our cardiac surgical centre. Indications for placing these patients on central VA ECMO included inability to wean from cardiopulmonary bypass (CPB), low cardiac output syndrome, severe pulmonary arterial hypertension, significant bleeding, anaphylaxis, respiratory failure and severe pulmonary edema. The mean time to initiation of ECMO was less than 5 h and the mean duration of ECMO support was 56 h with a survival rate of 58.3%. Amongst perioperative complications, sepsis and arrhythmia on ECMO were found to be negatively associated with survival. Improvements in the pH, PaO2 levels and serum lactate levels after initiation of ECMO were associated with survival benefits. The early initiation of ECMO for paediatric cardiotomies could be a beacon of hope for families and medical teams confronting these challenging situations. Improvement in indicators of adequate perfusion and ventricular recoveries like pH and serum lactate and absence of arrhythmia and sepsis are associated with good outcomes.

Caring for Patients Requiring Venous Arterial Extracorporeal Membrane Oxygenation: Can Upstream Palliative Care Make a Difference?

Palliative care consultation is relevant for patients requiring Venous-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO); however, evidence is limited to support its value. For this population, we compared length of stay (LOS) (primary outcome), operational metrics and goals of care (GOC) frequency before and after a collaboration between cardiothoracic (CT) surgery and Geriatrics and Palliative Medicine (GaP). Retrospective chart review of patients (18+) admitted to a quaternary center that required VA-ECMO between 2019-2021 and received GaP consultation. Demographics, LOS, times to consult, illness severity, GOC, and outcomes were analyzed. 120 patients met inclusion criteria and 64 (53.3%) had GaP consultation. No differences were observed regarding demographics and insertion status (emergent vs elective). Median (IQR) days to GaP consult for 2019, 2020 and 2021 were 6.5 (4.0-14.5), 5.0 (2.0-11.0) and 3.0 (2.0-5.0), respectively (P = .006). Median days from insertion to consult for 2019, 2020 and 2021 were 6.0 (4.0-20.0), 3.0 (1.0-6.0) and 2.0 (1.0-4.0) (P = .003). Among survivors, over the 3-year course, median LOS was not statistically different. Between expired patients, median (IQR) LOS for 2019, 2020, and 2021 was 28.5 (23.0-40.0), 12.0 (8.0-14.0), 11.0 (5.0-17.0) days (P = .013). For patients not seen by GaP, 8 (14.3%) GOC notes were documented, compared with 42 (65.6%) for patients seen. Mortality was similar (53.6% vs 53.1% [GaP]). For patient on VA-ECMO, early GaP consultation may improve hospital LOS and GOC rates. We suggest organizations consider early palliative integration when instituting mechanical circulatory support.

Modified Thermodilution for Simultaneous Cardiac Output and Recirculation Assessment in Veno-venous Extracorporeal Membrane Oxygenation: A Prospective Diagnostic Accuracy Study.

Thermodilution is unreliable in veno-venous extracorporeal membrane oxygenation (VV-ECMO). Systemic oxygenation depends on recirculation fractions and ratios of extracorporeal membrane oxygenation (ECMO) flow to cardiac output. In a prospective in vitro simulation, this study assessed the diagnostic accuracy of a modified thermodilution technique for recirculation and cardiac output. The hypothesis was that this method provided clinically acceptable precision and accuracy for cardiac output and recirculation. Two ECMO circuits ran in parallel: one representing a VV-ECMO and the second representing native heart, lung, and circulation. Both circuits shared the right atrium. Extra limbs for recirculation and pulmonary shunt were added. This study simulated ECMO flows from 1 to 2.5 l/min and cardiac outputs from 2.5 to 3.5 l/min with recirculation fractions (0 to 80%) and pulmonary shunts. Thermistors in both ECMO limbs and the pulmonary artery measured the temperature changes induced by cold bolus injections into the arterial ECMO limb. Recirculation fractions were calculated from the ratio of the areas under the temperature curve (AUCs) in the ECMO limbs and from partitioning of the bolus volume (flow based). With known partitioning of bolus volumes between ECMO and pulmonary artery, cardiac output was calculated. High-precision ultrasonic flow probes served as reference for Bland-Altman plots and linear mixed-effect models. Accuracy and precision for both the recirculation fraction based on AUC (bias, -5.4%; limits of agreement, -18.6 to 7.9%) and flow based (bias, -5.9%; limits of agreement, -18.8 to 7.0%) are clinically acceptable. Calculated cardiac output for all recirculation fractions was accurate but imprecise (RecirculationAUC: bias 0.56 l/min; limits of agreement, -2.27 to 3.4 l/min; and RecirculationFLOW: bias 0.48 l/min; limits of agreement, -2.22 to 3.19 l/min). Recirculation fraction increased bias and decreased precision. Adapted thermodilution for VV-ECMO allows simultaneous measurement of recirculation fraction and cardiac output and may help optimize patient management with severe respiratory failure.

Predictors on admission associated with successful weaning and in - hospital mortality in patients with refractory shock undergoing veno - arterial extracorporeal membrane oxygenation

Abstract Introduction In assessment of prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO), considerable data have been focused on predictors just before or after VA-ECMO initiation. The aim of this study is to determine the prognostic factors on admission in patients with refractory shock undergoing VA-ECMO. Methods A total of 307 patients (median age 57; interquartile rate [IQR]: 48-68, male 220 (72%)) who underwent VA-ECMO due to refractory shock from 2015 to 2021 were retrospectively analyzed. Successful weaning was defined as successful removal of VA-ECMO without mechanical support over the following 30 days. In-hospital mortality (IHM) was defined as death occurred during the hospital stay. Results Median duration of weaning and hospital stay was 10 days (IQR: 7-14) and 24 days (IQR: 9-43), respectively. Of all patients, 115 patients (37%) were successfully weaned from VA-ECMO and 191 (62%) died before discharge. Patients with successful weaning and survived before discharge had lower prevalence of sepsis, higher cystatin C based estimated glomerular filtration rate (cyc-eGFR) and total cholesterol, and lower blood urea nitrogen, C-reactive protein and INR on admission than those with failed weaning and those who had died. In multivariate regression analyses, sepsis, cyc-eGFR and INR on admission were independently associated with successful weaning and only cyc-eGFR on admission was remained as independent predictor of IHM. In an incremental model, the addition of cyc-eGFR significantly increased the χ² of the clinical and laboratory data model including creatinine based eGFR (Cr-eGFR), from 22.3 to 33.7 (p&amp;lt;0.001) for prediction of successful weaning and from 22.2 to 33.6 (p&amp;lt;0.001) for prediction of IHM, respectively. Conclusion Cyc-eGFR on admission showed an incremental prognostic value beyond Cr-eGFR on admission for prediction of successful weaning and IHM in patients with refractory shock undergoing VA-ECMO.

The Roles of Venopulmonary Arterial Extracorporeal Membrane Oxygenation.

Concise definitive review of the use of venopulmonary arterial extracorporeal membrane oxygenation (V-PA ECMO) support in patients with cardiopulmonary failure. Original investigations identified through a PubMed search with search terms "percutaneous right ventricular assist device," "oxy-RVAD," "V-PA ECMO," and "veno-pulmonary arterial ECMO" were reviewed and evaluated for relevance. Studies that included more than three patients supported with V-PA ECMO were included. Clinically relevant data from included studies, including patient-important outcomes, were summarized and discussed. We identified four groups of patients where V-PA ECMO has been studied: acute respiratory distress syndrome, right ventricular dysfunction after left ventricular assist device placement, bridge to lung transplantation, and pulmonary embolism. Most identified works are small, single center, and retrospective in nature, precluding definitive conclusions regarding the efficacy of V-PA ECMO. There have been no clinical trials evaluating the efficacy of V-PA ECMO for any indication. V-PA ECMO is a promising form of extracorporeal support for patients with right ventricular dysfunction. Future work should focus on identifying the optimal timing and populations for the use of V-PA ECMO.

OC 51.5 Outcomes Associated with the Use of Dual Antiplatelet Therapy in Patients Presenting with out of Hospital Cardiac Arrest Supported with Veno Arterial Extracorporeal Membrane Oxygenation

OC 51.5 Outcomes Associated with the Use of Dual Antiplatelet Therapy in Patients Presenting with out of Hospital Cardiac Arrest Supported with Veno Arterial Extracorporeal Membrane Oxygenation

Percutaneous left ventricular assist device as a short-term mechanical circulatory support before heart transplantation in patients with high pre-transplant pulmonary hypertension (series of clinical cases)

Federation In certain categories of patients with end-stage heart failure (HF), short-term mechanical circulatory support (MSC) is successfully used as a mechanical «bridge» to heart transplantation (HTx). In predominantly left-ventricular (LV) dysfunction, the use of isolated coronary artery bypass, especially amidst high pulmonary hypertension (PH), seems to be a more physiological method of short-term MSC.Objective: to present the results of a series of clinical cases of the use of percutaneous left ventricular assist device (pLVAD) before HTx in potential recipients with predominantly LV dysfunction and concomitant high PH.Materials and methods. Three potential heart recipients with predominantly left-sided HF and high pre-transplant PH (pulmonary vascular resistance, PVR, 4.7–6.6 Wood units) who required MSC due to progression of hemodynamic disorders were included in the study. A standard venous extracorporeal membrane oxygenation (ECMO) cannula (26 F) was used for percutaneous left atrial-femoral artery (LA–FA) bypass. The cannula was passed from the transfemoral route through the interatrial septum into the left atrial cavity. A paracorporeal centrifugal pump provided blood injection through a standard arterial ECMO cannula (15 F).Results. pLVAD unloaded the left ventricle effectively (PCWP reduced from 27–32 to 15–20 mmHg), reduced pre-transplant PH (mean pulmonary artery pressure (mPAP) reduced from 45–53 to 28–33 mmHg) and improved systemic hemodynamics (cardiac index (CI) increased from 1.8–1.9 to 2.1–2.6 l/min/m2 and mean arterial pressure (mAP) from 56–59 to 70–75 mmHg). All these created the prerequisites for subsequent successful HTx. Against the background of pLVAD, transpulmonary pressure gradient (TPG) decreased from 15–25 to 13–15 mmHg, and PVR decreased from 4.7–6.6 to 2.7–3.4 Wood units. pLVAD flow rate was 2.9–3.8 L/min or 1.38–1.83 L/min/m2 at 4700–7100 rpm. pLVAD duration ranged from 4 (n = 1) to 7 (n = 2) days. All patients underwent successful HTx.Conclusion. pLVAD is a highly effective method of short-term MSC in potential recipients with predominantly LV dysfunction and concomitant high PH, leading to rapid regression of the dysfunction against the background of left ventricular unloading. This short-term MSC technique can be successfully realized using standard ECMO cannulas and centrifugal pumps of any modification, without requiring additional special equipment.

P290 EXTRACORPOREAL MEMBRANE OXYGENATION SYSTEM AS A BRIDGE TO REPARATIVE SURGERY IN VENTRICULAR SEPTAL DEFECT COMPLICATING ACUTE MYOCARDIAL INFARCTION

Abstract Introduction Post–infarct ventricular septal defect (VSD) is a life tethering complication of acute myocardial infarction which is associated to high in–hospital mortality (90–95%). The optimal peri–operative management including timing of surgical correction is still debated. There is a large body of evidence demonstrating that surgical repair is also associated to poor post–operative outcomes due to cardiogenic shock and multiorgan failure (MOF). The use of extracorporeal membrane oxygenation (ECMO) system in adult cardiac surgery is not routine, occurring in a minority of critically ill patients, typically postoperatively. Here we present our single centre experience of patients with post–infarct VSD managed preoperatively with ECMO support as a bridge to definitive surgical closure. Materials and methods Between February 2020 to July 2021, 5 patients presented to our unit with diagnosis of post–infarct VSD and were managed with preoperative veno–arterial (V–A) ECMO implantation and enrolled in our study. Clinical parameters (such as mean arterial pressure, central venous pressure, ECG, pulmonary artery pressure), blood tests, trans–thoracic and trans–esophageal echocardiography, chest X–rays have been evaluated both before and after surgery. Primary end–point was all causes in–hospital mortality. Results Three (60%) patients were male and mean age was 70,4 (60–78) years. All patients underwent surgical repair. ECMO was positioned between 1 and 9 days prior to surgical correction, giving the chance to reduce the pharmacological inotropic support while still reverting the MOF as demonstrated by the reduction of AST, ALT, bilirubin level, decreased CVP and systemic lactate levels. Two (40%) patients were successfully weaned off from the mechanical support and discharged home in good clinical conditions. Two (40%) patients developed MOF after surgery leading to the exitus. Conclusions We postulate that the use of V–A use preoperatively in patients with cardiogenic shock secondary to post–infarct VSD is appropriate and where feasible should be considered. It allows restoration of haemodynamic stability and resolution of MOF. This provides for a delayed surgical repair with a likely higher chance of operative success and reduced mortality.

Cerebral Neural Changes in Venous–Arterial Extracorporeal Membrane Oxygenation Survivors

Extracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in patients with critical ailments, but very little is known about the functional cerebral changes in ECMO survivors. Degree centrality (DC), a graph-based assessment of network organization, was performed to explore the neural connectivity changes in ECMO survivors compared to controls and their correlation with cognitive and neurological measures. This exploratory observational study was conducted from August 2020 to May 2022. ECMO survivors and controls underwent functional magnetic resonance imaging (fMRI) of the brain. We performed DC analysis to identify voxels that showed changes in whole-brain functional connectivity with other voxels. DC was measured by the fMRI graph method and comparisons between the two groups were performed. All participants underwent neuropsychological assessment (Montreal Cognitive Assessment, MoCA). Blood serum neuron-specific enolase and the Glasgow Coma Scale (GCS) were assessed in ECMO survivors. DC values in the right insula and right precuneus gyrus were lower in ECMO survivors and higher in the right medial superior frontal gyrus compared to controls (all p < 0.001). Decreased connectivity in the right insular and right precuneus gyrus correlated with total MoCA scores, delayed recollection, and calculation (all p < 0.05). Increased serum NSE levels, GCS score, and GCS-motor response correlated with decreased connectivity in the right insular and right precuneus gyrus and increased connectivity in the right medial superior frontal gyrus (all p < 0.05). We showed that both functional impairment and adaptation were observed in survivors of ECMO, suggesting that neural connectivity changes may provide insights into the mechanisms that may potentially link ECMO survivors to neurological and cognitive disorders.

Veno-Pulmonary Arterial Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Should We Consider Mechanical Support of the Pulmonary Circulation From the Outset?

Veno-Pulmonary Arterial Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Should We Consider Mechanical Support of the Pulmonary Circulation From the Outset?

The Preventive Effect of Distal Perfusion Catheters on Vascular Complications in Patients Undergoing Venous Artery Extracorporeal Membrane Oxygenation.

To investigate the preventive effect of distal perfusion catheters (DPCs) on vascular complications in patients undergoing venous artery extracorporeal membrane oxygenation (VA-ECMO). Patients who underwent VA-ECMO through a femoral approach in our hospital were included in this study, and they were divided into two groups according to their use of DPC. Clinical indicators were compared between the two groups, including the ECMO running time, intensive care unit (ICU) time, length of hospital stay, ECMO auxiliary results, the incidence of limb ischemia and vascular complications. In total, 250 patients were included in this study, including the DPC group (age: 48 [32-62] years old, 58.4% male, n = 125) and the non-DPC group (age: 51 [36-63] years old, 65.6% male, n = 125). The DPC group was less likely to have limb complications than the non-DPC group (6.4% vs 17.6%, P = 0.006), mainly resulting from distal ischemia (4.0% vs 15.2%, P = 0.003) and necrosis (1.6% vs 9.6%, P = 0.006). The ECMO duration had a median of 92.3 (75.7-109) h in the DPC group and 71.2 (59.4-82.8) h in the DPC group, with a difference close to the statistical threshold (P = 0.054). There was no significant difference in ICU time or length of hospital stay between the two groups. The multivariate analysis showed that the DPC implantation was negatively associated with limb complications (odds ratio: 0.265, 95% confidence interval: 0.107-0.657, P = 0.004) after adjustment for confounding factors. Distal perfusion catheter placement might be associated with a decreased risk of vascular complications and limb ischemia in patients undergoing femoral VA-ECMO cannulation. Further randomised studies are still needed to verify its benefit on clinical outcomes.

Long-term ECMO, efficiency and performance of EUROSETS adult A.L.ONE ECMO oxygenator

BackgroundThe management of the oxygenator can be prolonged in the long-term procedures especially during extracorporeal membrane oxygenation (ECMO) for bridge to transplant or bridge to recovery. Long-term use often involves an overrun of the time of use with respect to certification of the oxygenating module of 14 days, for the maintenance of performance and efficiency of the oxygenator. The evaluation of the long-term oxygenator efficiency is complex and depends on the: patient pathology, ECMO configuration, the management of coagulation and anticoagulation, materials selection and circuit components, the structure, design and performance of the oxygenator. In this context we investgated the long-term performance of the A.L.ONE Eurosets ECMO oxygenator in relation to the parameters prodromal to replacement.MethodsWe retrospectively collected eight years data from Anthea Hospital GVM Care & Research, Bari, Italy on the long-term use exceeding 14 days of Eurosets A.L.ONE ECMO Adult oxygenator in Polymetylpentene fiber, for ECMO procedures, including the procedures: Veno Arterial (VA) ECMO post-cardiotomy or not, veno-venous (VV) ECMO. The primary end points were the evaluation of Gas Transfer: oxygen partial pressure (PO2) post oxygenator, Carbon dioxide partial pressure (PCO2) post oxygenator, the oxygen transfer across the oxygenator membrane V′O2, differential CO2 content across oxygenator; Pressure monitoring: oxygenator pressure Drop in relation to Blood flow rate (BFR) (ΔP); Hematologic values: Hemoglobin, Fibrinogen, Platelets, aPTT, D-Dimer, LDH.ResultsNine VA ECMO patients who used the oxygenator for 18.5 days and two VV ECMO patients who used the oxygenators for 17.2 days on the seventeenth days reported average values PaO2 (267 ± 29 mmHg); PaCO2 (34 ± 4 mmHg) with gas blender values set to 3.8 ± 0.6 L/min of air and a FiO2 of 78 ± 5%; the transfer across the oxygenator membrane V′O2 was 189 ± 43 (ml/min/m2). The mean peak of partial pressure of carbon dioxide from the gas exhaust of oxygenator (PECO2) was 38 ± 4 mmHg; differential CO2 across the oxygenator “pre-oxygenator PCO2–post-oxygenator PCO2” (18 ± 6 mmHg); the mean blood flow rate (BFR) 4.5 ± 0.6 (L/minute); the pump revolution per minutes mean maximum rate was 4254 ± 345 (RPM); the mean pressure drop (ΔP) was 76 ± 12 mmHg; the mean peak of d-dimers (DDs) was 23.6 ± 0.8 mg / dL; the mean peak of LDH was 230 ± 55 (mg/dl); fibrinogen mean peak 223 ± 40 (mg/dl).ConclusionsThe performance of the Eurosets A.L.ONE ECMO Adult polymethylpentene fiber oxygenator in our experience has proven efficiency in terms of O2 uptake and CO2 removal, blood fluid dynamics, metabolic compensation and heat exchange in the long-term treatment. The device was safe without iatrogenic problems over a period of 14 days in the patients undergoing ECMO VA and in all patients undergoing VV ECMO with continuous administration of anticoagulation therapy.

Sepsis in postcardiotomy cardiogenic shock patients supported with veno- arterial extracorporeal membrane oxygenation.

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. 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). 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). 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.

Extracorporeal membrane oxygenation for large pulmonary emboli

Massive and submassive pulmonary emboli (PE) are increasingly being treated with percutaneous lytic and embolectomy procedures. While these procedures are overwhelmingly safe, patients with significant right ventricular strain are at risk for hemodynamic compromise requiring extracorporeal membrane oxygenation (ECMO). We conducted a retrospective study of all patients requiring ECMO support for PE from 2014 through 2022. The primary outcome was survival. Secondary outcomes included commonly encountered ECMO complications. From 2014 to 2022, 10 patients with submassive or massive PE required ECMO support. All 10 patients (100%) had right ventricular strain on echocardiography, 7 (70%) had a saddle PE, and 3 (30%) had extensive bilateral PE. Six (60%) patients required cardiopulmonary resuscitation prior to ECMO cannulation, and 4 (40%) were undergoing cardiopulmonary resuscitation while being cannulated. Nine (90%) patients were placed on venoarterial ECMO through the femoral vessels, while 1 (10%) was cannulated with right atrial to pulmonary artery ECMO. The median duration of support was 4 [3–8] days. During their course, 5 patients underwent percutaneous embolectomy, 1 underwent surgical embolectomy, and 4 underwent percutaneous lytic therapy. All patients (100%) survived to ECMO decannulation, and 6 (60%) survived to discharge. With a mean follow-up of 496 days, there were no postdischarge mortalities. In conclusion, although therapy for large PE is well tolerated, a small number of patients will experience periprocedural hemodynamic collapse requiring ECMO support. ECMO for PE patients is associated with acceptable morbidity and mortality. Further investigation is warranted to better characterize which patients are likely to require ECMO support.

182: POST-DECANNULATION ANALGOSEDATION WEANING IN COVID-19 EXTRACORPOREAL MEMBRANE OXYGENATION PATIENTS

Introduction: COVID-19-associated acute respiratory distress syndrome (ARDS) has necessitated the use of extracorporeal membrane oxygenation (ECMO) to support patients with impaired respiratory function. Reports of increased analgosedation requirements in COVID-19 patients receiving ECMO highlight the possible challenges of weaning analgesia and sedation once these patients are decannulated. Methods: This retrospective cohort analysis investigated analgesia and sedation requirements in COVID-19 and non-COVID-19 patients after venovenous (VV) or venopulmonary artery (VPa) ECMO decannulation. The primary outcome was time to weaning of parental analgosedation. Secondary objectives included incidence of enteral analgosedative use to facilitate weaning of parenteral agents, discharge analgesia and sedative prescribing patterns, and incidence of weaning failure. Results: A total of 58 patients were included; 32 COVID-19 ECMO and 26 non-COVID-19 ECMO patients. There was a higher incidence of prolonged weaning post-decannulation in the COVID-19 group compared to the non-COVID-19 group (59.4% vs. 46.2%, P = 0.43). The median (IQR) time to weaning of all parenteral agents was 8 days (4-13) in the COVID-19 group and 6 days (2-10) in the non-COVID-19 group (P = 0.32). Of all agents, median duration to wean dexmedetomidine was longest in both the COVID-19 and non-COVID-19 groups [9.25 days (3.75-13); 4.75 days (2-6.75) (P = 0.15)]. COVID-19 patients had a higher incidence of antipsychotic use to facilitate weaning (88% vs. 65%, P = 0.06) and prescription on discharge (47% vs. 27%, P = 0.17). Approximately 19% of patients in each group experienced failure to wean parenteral analgosedation and required re-initiation of parenteral agents during the post-decannulation period. Conclusions: Weaning of analgosedation was longer in COVID-19 ECMO patients following decannulation. COVID-19 ECMO patients also required greater addition of enteral therapies to manage analgesia and sedation in the post-decannulation period. Future studies are needed to investigate strategies to optimize sedation in these patients.

Abstract 13939: Catecholamine-Induced Cardiomyopathy and Limb Ischemia in Pheochromocytoma

Case Presentation: A 40-year-old woman who was 4 weeks pregnant presented with nausea and vomiting. Blood pressure (BP), heart rate, and temperature were 180/104 mmHg, 85 beats/min, 36.1℃ (96.98 ℉), Hypoxemia and mild pulmonary edema were observed. Echocardiography showed severe left ventricular dysfunction and normal dimension with ejection fraction &lt; 10 %. As BP was decreased despite inotropic agents with aggravated hypoxemia, deteriorated acute kidney injury, mechanical ventilation, venous arterial extracorporeal membrane oxygenation (VA-ECMO), and continuous renal replacement therapy were initiated. Coronary angiography revealed normal coronary arteries and the possibility of myocarditis was low because endomyocardial biopsy showed rare inflammatory infiltration. After a few days, other parameters including cardiac function were improved and VA-ECMO was stopped, however, ischemic signs of the right lower leg progressed. To rule out rhabdomyolysis and compartment syndrome, CT angiography was done and about 4.9 cm sized left adrenal mass was found (A). The results of catecholamines are as follows: plasma metanephrine, 1862.6 (&lt; 98.6 pg/mL); normetanephrine, 993.8 (&lt; 164.9 pq/mL); 24hr urine metanephrine, 1396.2 (36~229 mcg/24hr); normetanephrine, 835.8 (95~650 mcg/24hr). A diagnosis of pheochromocytoma was made and left adrenalectomy was done, Pheochromocytoma was demonstrated in biopsy. Unfortunately, due to severe vasoconstriction and rhabdomyolysis, her right leg was not completely recovered, so amputation was done below knee (B). Discussion: Pheochromocytomas are catecholamine secreting tumors derived from chromaffin cells in the adrenal medulla. Catecholamine-induced vasoconstriction, microvascular hypoxia, muscle ischemia, direct toxic effects are considered to contribute to cardiomyopathy and limb ischemia in rare situations. Timely clinical suspicion, prompt diagnosis, and therapeutic intervention are critical.

Improving Extracorporeal Membrane Oxygenation Survival in COVID-19. Effect of a Bundle of Care.

Veno-venous extracorporeal membrane oxygenation (ECMO) support surged during the COVID-19 pandemic. Our program changed the model of care pursuing to protect the multidisciplinary team from the risk of infection and to serve as many patients as possible. Patient–healthcare interactions were restricted, and the ECMO bed capacity was increased by reducing the ECMO specialist–patient ratio to 1:4 with non-ECMO trained nurses support. The outcomes worsened and we paused while we evaluated and modified our model of care. The ECMO bed capacity was reduced to allow a nurse ECMO–specialist nurse ratio 2:1 with an ECMO trained nurse assistant’s support. Intensivists, general practitioners, nurse assistants, and physical and respiratory therapists were trained on ECMO. Tracheostomy, bronchoscopy, and microbiological molecular diagnosis were done earlier, and family visits and rehabilitation were allowed in the first 48 hours of ECMO cannulation. There were 35 patients in the preintervention cohort and 66 in the postintervention cohort. Ninety days mortality was significantly lower after the intervention (62.9% vs. 31.8%, p = 0.003). Factors associated with increased risk of death were the need for cannulation or conversion to veno arterial or veno arterio venous ECMO, hemorrhagic stroke, and renal replacement therapy during ECMO. The interventions associated with a decrease in the risk of death were the following: early fiberoptic bronchoscopy and microbiological molecular diagnostic tests. Increasing the ECMO multidisciplinary team in relation to the number of patients and the earlier performance of diagnostic and therapeutic interventions, such as tracheostomy, fiberoptic bronchoscopy, molecular microbiological diagnosis of pneumonia, rehabilitation, and family support significantly decreased mortality of patients on ECMO due to COVID-19.