Arteriovenous Extracorporeal Membrane Oxygenation Research Articles

Takotsubo cardiomyopathy after cardiac surgery: A case-series and systematic review of literature.

Takotsubo cardiomyopathy (TTC) is a rare entity after cardiac surgery. To describe patients' profile who developed postoperative TTC after cardiac surgery, management, and outcomes. We performed a systematic literature search to extract cases of TTC after adult cardiac surgery (from 1990 to 2021). Additionally, we extracted all cases of TTC in a prospective single-center cohort database of 10,000+ patients (from 2007 to 2019). We then combined all cases in a single cohort to describe its clinical features. From 694 screened articles, we retained 71 individual cases published in 20 distinct articles (19 cases reports and 1 case-series). We combined these to 10 cases extracted from our cohort [among 10,682 patients (0.09%)]. Overall, we included 81 cases. Patients were aged 68 ± 10 years-old and 64/81 (79%) were women. Surgery procedures included mitral valve and/or tricuspid valve surgery in 70/81, 86%. TTC was diagnosed in the first days after surgery [median 4 (1-4) days]. Incidence of cardiogenic shock, defined as requirement of vasopressor and/or inotropic support was 24/29, 83% (data available on 29/81 patients). Refractory cardiogenic appeared in 5/81, 6% who required implantation of arterio-venous extra-corporeal membrane oxygenation, and 6/81, 7%, intra-aortic balloon pump. In-hospital mortality was 5/81, 6%. This systematic review, based on case reports and case series, showed that postoperative TTC appears as a rare complication after cardiac surgery and mainly occurred after mitral and/or tricuspid valve repair procedures. In this population, TTC is associated with high rate of cardiogenic shock.

Extracorporeal cardiopulmonary resuscitation for treatment of out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) affects ca. 75,000 people each year in Germany and is associated with a limited prognosis and a high mortality. Extracorporeal cardiopulmonary resuscitation (eCPR) using arteriovenous extracorporeal membrane oxygenation (av-ECMO) systems is an additional option for treatment, which is increasingly more widespread and since 2020 anchored in the guideline algorithm. A selective search of the literature was carried out in PubMed and Embase focusing on studies that investigated eCPR for OHCA. Furthermore, clinical studies on this topic that are currently recruiting and running are summarized. The available data on the benefits of eCPR for OHCA are mostly based on retrospective cohort studies. A survival advantage and an advantage in the neurological outcome could be derived from these data for selected patients treated with eCPR vs. conventionally resuscitated patients (CPR). This effect could be confirmed by two current randomized controlled studies. Studies which are currently running are investigating if out-of-hospital ECMO cannulation at the earliest time possible at the site of OHCA of patients could be associated with a better survival. Despite a current scarcity of data, a survival advantage for eCPR treatment in selected OHCA patients must be assumed. If this can be substantiated by other high-quality studies, it seems to be indicated to evaluate if and to what extent resource-intensive eCPR programs can be comprehensively established.

Platelet Desialylation Is a Novel Mechanism of Thrombocytopenia during Mechanical Circulatory Assistance

Introduction: Although bleeding associated with thrombocytopenia often complicates mechanical circulatory assistance (MCA), the mechanisms of thrombocytopenia observed in this high shear stress situation remain poorly understood. Recent studies have highlighted that platelet desialylation, a process in which terminal sialic acids are cleaved from glycoconjugates on the platelet surface, leads to accelerate platelet clearance via asialoglycoprotein receptors on hepatocytes and subsequent thrombocytopenia. Moreover, it was demonstrated that platelet receptor GPIba occupancy by plasma protein von Willebrand factor (VWF) under physiological shear stress induces platelet desialylation. As MCA promotes, in the majority of patients, high shear-induced VWF/GPIba interactions, we aimed to investigate whether the thrombocytopenia observed during MCA depends on platelet desialylation.Methods: The effects of MCA on platelet desialylation were assessed i) in vitro using human whole blood or platelets rich plasma (PRP) and an Impella (Abiomed Europe GmbH, Aachen, Germany) circulatory assistance pump providing flow rate of 5 liters by minute and inserted in a loop and ii) in 11 adult patients requiring arteriovenous extracorporeal membrane oxygenation (ECMO) circulatory assistance. Platelet desialylation was measured by flow cytometry using fluorescent lectin, at baseline and after initiation (5, 30, 60, 120 and 180 minutes and 24 hours for patients) of MCA. The blood platelet count and the immature platelet fraction (IPF), a new parameter that reflects the activity of thrombopoiesis, were also determined in patients at baseline and daily after ECMO initiation.Results: In vitro, platelet desialylation levels in whole blood and in PRP increased after 5 minutes of circulatory assistance pump compared to baseline (+216%, p<0.05 and +132%, p<0.05, respectively) and the difference persists over time (at 180 minutes: +244%, p<0.05 in whole blood and +292%, p<0.05 in PRP). In all patients, platelet desialylation levels were higher after 5 minutes of ECMO compared to baseline (+197%, p<0.001) and as in vitro, the difference persist over time (at 180 minutes: +187%, p<0.05 and at 24 hours: +223%, p<0.05). In parallel, a decrease of platelet counts and an increase of IPF were observed in all these patients after 2 days under ECMO with a nadir at 4 days for platelet counts (73 G/L, range: 27-119 G/L) and a zenith at 3 days for IPF (13.75%, range: 5.5-22.0%).Conclusion: The present study is the first to show that MCA increases platelet desialylation within minutes after pump initiation. Thus, thrombocytopenia observed in this context seems dependent on platelet desialylation. Giving these results, further studies evaluating the potential beneficial effects of desialylation inhibitors to prevent or treat MCA associated thrombocytopenia could be valuable. DisclosuresNix:Abiomed: Employment.

Establishment and evaluation of a rat model of extracorporeal membrane oxygenation (ECMO) thrombosis using a 3D-printed mock-oxygenator

BackgroundExtracorporeal membrane oxygenation (ECMO) research using large animals requires a significant amount of resources, slowing down the development of new means of ECMO anticoagulation. Therefore, this study developed and evaluated a new rat ECMO model using a 3D-printed mock-oxygenator.MethodsThe circuit consisted of tubing, a 3D-printed mock-oxygenator, and a roller pump. The mock-oxygenator was designed to simulate the geometry and blood flow patterns of the fiber bundle in full-scale oxygenators but with a low (2.5 mL) priming volume. Rats were placed on arteriovenous ECMO at a 1.9 mL/min flow rate at two different heparin doses (n = 3 each): low (15 IU/kg/h for eight hours) versus high (50 IU/kg/h for one hour followed by 25 IU/kg/h for seven hours). The experiment continued for eight hours or until the mock-oxygenator failed. The mock-oxygenator was considered to have failed when its blood flow resistance reached three times its baseline resistance.ResultsDuring ECMO, rats maintained near-normal mean arterial pressure and arterial blood gases with minimal hemodilution. The mock-oxygenator thrombus weight was significantly different (p < 0.05) between the low (0.02 ± 0.006 g) and high (0.003 ± 0.001 g) heparin delivery groups, and blood flow resistance was also larger in the low anticoagulation group.ConclusionsThis model is a simple, inexpensive system for investigating new anticoagulation agents for ECMO and provides low and high levels of anticoagulation that can serve as control groups for future studies.

Abstract 16208: Safety and Efficacy of Arterio-venous Extracorporeal Membrane Oxygenation (SAVE Study) Cannulation by Interventional Cardiologists for Pediatric Population: Results of a Single Center Pilot Study

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulations have been successfully performed in adults by interventional cardiologists (IC) for cardiopulmonary resuscitation (CPR) but little data exists in children. Hypothesis: This study aimed to describe the safety and efficacy of ultrasound-guided percutaneous VA-ECMO cannulation performed by IC for cardiopulmonary resuscitation. Methods: VA-ECMO cannulation performed by IC for CPR between January 2018 - June 2020 in a tertiary care children’s hospital were reviewed. Efficacy was defined as successful initiation of VA-ECMO following CPR without a surgical cut-down. Safety was defined as the absence of the need for additional procedures related to the cannulation event. Results: Eight VA-ECMO cannulations were attempted on 7 patients with 100% success; 1 patient was cannulated twice at 2 separate CPR events. Patients had congenital heart disease (n=3), idiopathic pulmonary hypertension (n=1), T-cell lymphoma (n=1) and dilated cardiomyopathy (n=2). Median age was 15 (6-18) years, median weight was 74 (16-109) kg. Uninterrupted CPR occurred during all cannulations. All cannulations were performed from left femoral artery and right femoral vein, 4 (50%) cannulations included additional internal jugular vein access. Reperfusion cannulation for distal limb circulation was also performed percutaneously by IC for 5 cannulations. Median venous cannula size was 22 (15-25) Fr and median arterial cannula size was 17 (15-17) Fr. Median cannulation start time to ECMO flow was 34.5 (18-112) min. Median ECMO duration was 3 (0.3-50) days. Survival at ECMO decannulation was 75% with a 30-day survival of 87.5%. The overall complication rate was 12.5%. One patient developed hematoma at cannulation site that was conservatively managed, and 1 patient (16 kg) developed avulsion of the intima of the left common femoral artery that needed repair. A cardiovascular surgeon was available or present during all ECMO cannulations. Conclusions: Pediatric VA-ECMO cannulation for CPR can be performed safely and efficiently by IC without interruption. Larger studies and further investigations are necessary especially in smaller children before advocating for its routine practice.

The Effects of Nitric Oxide in Oxygenator Sweep Gas During Extracorporeal Circulation in a Neonatal Ovine Model.

Extracorporeal membrane oxygenation is a life-saving intervention, but bleeding complications are frequent. Given that the combination of platelet loss and dysfunction is a major contributor to this acquired bleeding diathesis, efforts to combat these phenomena are of great clinical importance. In this study, we investigated the effects of nitric oxide (NO) added to the sweep gas of an extracorporeal circuit in a neonatal ovine model. Eight lambs (age 9.6 ± 1.9 days) were cannulated via the neck vessels and maintained on a pumpless arteriovenous extracorporeal membrane oxygenation circuit with blood flow restricted to 100 ml/min for 72 hours. All animals were heparinized, and a subset (n = 4) also received NO in the sweep gas at a concentration of 200 ppm. We observed no adverse effects from NO administration, and methemoglobin levels remained unchanged. Platelet counts significantly declined in all animals over the course of the study; however, mean counts were higher in the NO-treated group, and this difference was statistically significant at 24 hours (62 ± 3% vs. 32 ± 7% of baseline, P < 0.01). Likewise, mean plasma levels of beta-thromboglobulin, a marker of platelet activation, were lower in the NO-treated group, and this difference was also significant at the 24 hour time point (9.5 ± 2.2 vs. 19.7 ± 6.5 pg/mL/10 platelets, P < 0.05). We conclude that 200 ppm NO can be safely blended into the oxygenator sweep gas of a low-flow extracorporeal circuit and that it may transiently attenuate platelet consumption and activation.

Pumpless arteriovenous extracorporeal membrane oxygenation: A novel mode of respiratory support in a lamb model of congenital diaphragmatic hernia

BackgroundExtracorporeal membrane oxygenation (ECMO) is commonly required in neonates with congenital diaphragmatic hernia (CDH) complicated by pulmonary hypertension (PH). ECMO carries significant risk, and is contraindicated in the setting of extreme prematurity or intracranial hemorrhage. Pumpless arteriovenous ECMO (P-ECMO) may represent an alternative for respiratory support. The present study summarizes our initial experience with P-ECMO in a lamb model of CDH. Study designSurgical creation of CDH was performed at 65–75days' gestation. At term (135–145days), lambs were delivered into the P-ECMO circuit. Three animals were maintained on a low-heparin infusion protocol (target ACT 160–180) and three animals were maintained with no systemic heparinization. ResultsAnimals were supported by the circuit for 380.7 +/− 145.6h (range, 102–504h). Circuit flow rates ranged from 97 to 208ml/kg/min, with adequacy of organ perfusion demonstrated by stable serum lactate levels (3.0 +/− 1.7) and pH (7.4 +/− 0.3). Necropsy demonstrated no evidence of thrombogenic complications. ConclusionPumpless extracorporeal membrane oxygenation achieved support of CDH model lambs for up to three weeks. This therapy has the potential to bridge neonates with decompensated respiratory failure to CDH repair with no requirement for systemic anticoagulation, and may be applicable to patients currently precluded from conventional ECMO support.

Clinical course and prognostic factors of patients in severe accidental hypothermia with circulatory instability rewarmed with veno-arterial ECMO - an observational case series study

BackgroundRecently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatmentMethodsFrom July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients’ condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters.ResultsNine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO3) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment.Discussion and ConclusionsIn our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.

Pulmonary arteriovenous extracorporeal membrane oxygenation to avoid pulmonary overflow during total artificial heart implantation.

Total artificial hearts (TAH) can be used as a bridge to transplant or, occasionally, as destination therapy for patients with severe biventricular dysfunction. Not infrequently TAHs are placed in patients with severe low flow states, in which the lungs of these patients are unable to adjust rapidly to the "normal" right ventricular output of a TAH. These patients may develop variable degrees of pulmonary edema secondary to stress failure of the pulmonary capillaries requiring increased respiratory support, which can occasionally be fatal. In this "how to do it" article, we describe the technique for a pulmonary arteriovenous extracorporeal membrane oxygenation with TAH to avoid sudden pulmonary overflow and gradually expose the lungs to increasing flow.

Embolie pulmonaire révélée par un état de mal épileptique

High-risk pulmonary embolism (PE) is associated with high mortality rate (>50%). In some cases, diagnosis of PE remains a challenge with atypical presentations like in this case report with a PE revealed by status epilepticus. We report the case of a 40-year-old man without prior disease, hospitalized in ICU for status epilepticus. All paraclinical examinations at admission did not show any significant abnormalities (laboratory tests, cardiologic and neurological investigations). On day 1, he presented a sudden circulatory collapse and echocardiography showed right intra-auricular thrombus. He was treated by thrombolysis and arteriovenous extracorporeal membrane oxygenation. After stabilization, computed tomography showed severe bilateral PE. He developed multi-organ failure and died 4days after admission. Pulmonary embolism revealed by status epilepticus has rarely been reported and is associated with poor prognosis. Physicians should be aware and think of the possibility of PE in patients with status epilepticus without any history or risk factors of seizure and normal neurological investigations.

The chain of survival in hypothermic circulatory arrest: encouraging preliminary results when using early identification, risk stratification and extracorporeal rewarming.

BackgroundThe prognosis in hypothermic cardiac arrest is frequently good despite prolonged period of hypoperfusion and cardiopulmonary resuscitation. Apart from protective effect of hypothermia itself established protocols of treatment and novel rewarming techniques may influence on outcome.The purpose of the study was to assess the outcome of patients with hypothermic circulatory arrest treated by means of arterio-venous extracorporeal membrane oxygenation (ECMO) according to locally elaborated protocol in Severe Accidental Hypothermia Center in Cracow, Poland.MethodsProspective observational case-series study – all patients with confirmed hypothermic cardiac arrest consulted with hypothermia coordinator were accepted for extracorporeal rewarming, unless contraindications for ECMO were observed (active bleeding).ResultsThe study population consisted of 10 patients (7 male, median age 48.5 years). The core temperature measured esophageally was 16.9–28.4 °C, median 22 °C. On admission 5 patients presented with asystole and 5 with ventricular fibrillation. Duration of circulatory arrest before ECMO implantation was 107 to 345 min (median 156 min). The duration of ECMO support was 1.5 to 91 h (median 22 h). Cardiorespiratory stability and full neurologic recovery was achieved in 7 patients. The duration of mechanical ventilation was 88–437 h (median 177 h) and the length of stay in the ICU was 8–26 days (median 15 days). All survivors had mildly impaired (1 patient, LVEF 40 %) or preserved (6 patients, LVEF 55–65 %) left ventricular systolic function at the time of discharge from ICU. The cause of death of non-survivors (three patients) was acute myocarditis, massive retroperitoneal bleeding, and massive gastrointestinal bleeding.Discussion and ConclusionsOur data confirm the high survival rate (70 %) and excellent neurologic outcome in hypothermic cardiac arrest. The following key elements seem to impact the final prognosis: the appropriate coordination of the rescue operation, immediate high-quality CPR (preferably using mechanical chest compression system) and application of ECMO for rewarming and cardiorespiratory support.

Pentobarbital-Induced Myocardial Stunning in Status Epilepticus Requiring Extracorporeal Membrane Oxygenation: A Case Report and Literature Review.

Introduction. Mild hypotension is a well-recognized complication of intravenous pentobarbital; however fulminant cardiopulmonary failure has not been previously reported. Case Report. A 28-year-old woman developed pentobarbital-induced cardiopulmonary failure that was successfully treated with maximal medical management including arteriovenous extracorporeal membrane oxygenation. She made an excellent cardiopulmonary and neurological recovery. Discussion and Conclusion. Pentobarbital is underrecognized as a potential cause of myocardial stunning. The mechanism involves direct myocardial depression and inhibition of autonomic neuroanatomical structures including the medulla and hypothalamus. Early recognition and implementation of aggressive cardiopulmonary support are essential to optimize the likelihood of a favorable outcome.

Extracorporeal membrane oxygenation as a support for emergency bronchial reconstruction in a traumatic patient with severe hypoxaemia: Figure 1:

Extracorporeal membrane oxygenation (ECMO) is an extracorporeal life support technique to provide cardiac and/or respiratory assistance to patients. ECMO has been demonstrated to be beneficial for the life support of selected traumatic individuals. However, the application of arteriovenous ECMO as an intraoperative support strategy in emergency operations has rarely been described. The presented case involves a 31-year old male who sustained a right bronchial rupture and other multiple injuries in a car accident. His right main bronchus was sewn completely closed during the first operation in a local hospital, and he developed refractory hypoxaemia and haemodynamic instability. Although general anaesthesia was not applicable, arteriovenous ECMO was applied as a support to perform the second operation to reconstruct successfully his right main bronchus. As a result, he recovered from this injury.

Oxigenação extracorpórea por membrana em cães sem auxílio circulatório

A oxigenação extracorpórea por membrana com desvio arterio-venoso (AV-ECMO), em seres humanos, é uma técnica de suporte à vida capaz de assumir em parte ou totalmente as funções dos pulmões, quando estes já não são capazes de promover uma adequada hematose. Para conhecer a viabilidade deste método em cães (Canis familiaris), o presente estudo aplicou a AV-ECMO em dez indivíduos adultos, sem raça definida, com uma expectativa de três horas de duração para cada experimento. No grupo 1 (n=4), ventilação mecânica e infusão contínua de dopamina foram associadas ao suporte extracorpóreo. No grupo 2 (n=6), nenhuma medida de terapia intensiva foi instituída concomitantemente à AV-ECMO. O comportamento dos parâmetros de gasometria e os níveis de lactato foram avaliados a cada 10 minutos e 1 hora, respectivamente, por meio de da avaliação de amostras sanguíneas arteriais. O suporte inotrópico foi capaz de promover uma melhor perfusão tecidual com sangue oxigenado, sugerida pelos níveis de lactato e pressão arterial média mensurados, assim como a hemogasometria revelou melhores resultados quando a ventilação mecânica foi utilizada simultaneamente à AV-ECMO. Portanto, aplicada conjuntamente com suporte da terapia intensiva, a AV-ECMO é uma técnica viável para o uso em cães com falência respiratória, refratária aos tratamentos convencionais.

Successful Use of Fondaparinux in a Patient with Heparin-induced Thrombocytopenia while on Extracorporeal Membrane Oxygenation after Mitral Valve Redo Surgery

In patients with respiratory failure and impairment of the left ventricle, arteriovenous extracorporeal membrane oxygenation (ECMO) offers further therapeutic options. Systemic anticoagulation is mandatory and heparin is routinely administrated. However, repeated exposure to heparin may cause heparin-induced thrombocytopenia (HIT) and carries a risk of thrombotic mortality and morbidity. We present a patient who developed HIT during ECMO support and was treated successfully and safely by fondaparinux. Fondaparinux can be used for thromboembolic treatment or prophylaxis in a patient with HIT.

Extracorporeal membrane oxygenation in refractory cardiogenic shock - the Leipzig ECMO registry

Purpose: With mortality rates approaching 50%, prognosis of cardiogenic shock remains poor. According to current guidelines of the European Society of Cardiology, implantation of left ventricular assist devices such as extracorporeal membrane oxygenation (ECMO) may be considered to achieve hemodynamic stability in patients with refractory cardiogenic shock. However, data on clinical outcome in patients treated with ECMO in clinical routine are scarce. Here we report the in-hospital outcome and predictors for mortality in patients undergoing ECMO implantation due to refractory cardiogenic shock in a high volume tertiary care centre. Methods: Between 2008 and 2012, 85 patients with refractory cardiogenic shock underwent femoral percutaneous arteriovenous ECMO implantation performed by interventional cardiologists. A detailed set of clinical, therapeutic and laboratory parameters was assessed in all patients. Survival at hospital discharge was surveyed and independent predictors for mortality were identified. Results: Mean age was 60.6±14.4 years (range 23-84), 76.4% of all patients (n=65) were male and mean left ventricular ejection fraction was 28±17% (range 5-55). The majority of all patients underwent cardiopulmonary resuscitation prior to ECMO implantation (n=48, 56.4%). Indications for ECMO were cardiogenic shock complicated by acute coronary syndrome (n=54, 63.6%), acute non-ischemic heart failure (n=19, 22.4%), deterioration of valvular heart disease (n=9, 10.5%) and interventional complications during percutaneous coronary intervention (n=3, 3.5%). Mean ECMO support lasted 7.2±6.8 days (range 1-54). Despite initial successful ECMO weaning in 48 patients (56.4%), in-hospital mortality was 70.5% as only 25 patients were alive at discharge. Finally, age was identified as the only independent predictor for mortality (HR 1.04, 95% CI 1.01-1.08, p=0.02). No patient over the age of 75 years survived. Conclusion: Despite ECMO support, in-hospital mortality of patients with cardiogenic shock refractory to standard treatment remains high. However, especially in younger patients ECMO is a therapeutic option in this otherwise futile situation.

Oxigenación con membrana extracorpórea en la disfunción primaria del injerto en trasplante bipulmonar pediátrico: a propósito de un caso

Primary graft dysfunction is a leading cause of morbimortality in the immediate postoperative period of patients undergoing lung transplantation. Among the treatment options are: lung protective ventilatory strategies, nitric oxide, lung surfactant therapy, and supportive treatment with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery of lung function or re-transplant.We report the case of a 9-year-old girl affected by cystic fibrosis who underwent double-lung transplantation complicated with a severe primary graft dysfunction in the immediate postoperative period and refractory to standard therapies. Due to development of multiple organ failure, it was decided to insert arteriovenous ECMO catheters (pulmonary artery-right atrium). The postoperative course was satisfactory, allowing withdrawal of ECMO on the 5th post-surgical day. Currently the patient survives free of rejection and with an excellent quality of life after 600 days of follow up.

Double Jeopardy : Acute myocardial infarction complicated by cardiogenic shock and contrast mediated anaphylactoid reaction

A 63 year-old woman who developed a severe anaphylactoidreaction to iodinated contrast in the setting of emergent percutaneous intervention(PCI) for a large anterior wall ST elevation myocardial infarction (STEMI) resulting incardiogenic shock followed by cardiopulmonary arrest necessitating placement of the patient on the arterio-venous extra corporeal membrane oxygenation (ECMO). While anaphylactoid/anaphylactic reactions to radiocontrast agents have been well documentedin literature, the development of an anaphylactoid reaction secondary to radiocontrastmedia in the setting of an ST elevation myocardial infarction (STEMI) and resultingin cardiogenic shock has never been reported. We discuss naphylactoidreactions to contrast media occurs by non-immunologic (i.e. non IgE ) mechanisms. Premedication does not abate or prevent all types of iodinated contrastmediated reactions. However, studies have shown that premedication is effective fora cutaneous reaction to iodinated contrast media (ICM). Due to the relative excellentsafety profiles of the premedication, physicians should continue to use them prior to asuspected ICM reaction.

Initial Experience of Lung Transplantation at a Single Center in China

ObjectivesLung transplantation (LT) remains the only available option for patients with end-stage lung disease. Until recently, 244 lung transplantations have been performed at approximate 20 institutes in China. The aim of this article was to present the initial experience of LT at a single center in China. MethodsWe performed a retrospective review of the database from The Chinese Organ Transplantation Network between January 1978 and December 2010 with detailed records available at our center. ResultsWe performed 100 of 244 lung transplantions at the Wuxi Center, The remaining procedures were performed at other institutes. The overall survival rates for these patients at 1, 2, 3, and 5 years were 73.3%, 61.6%, 53.5%, and 40.7%, respectively. The indications for lung transplantation included idiopathic pulmonary fibrosis (n = 47), chronic obstructive pulmonary disease (n = 33), silicosis (n = 5), bronchiectasis (n = 5), and Eisenmenger's syndrome (n = 4). The procedure types consisted of single-lung transplantations (s; n = 72), and bilateral lung transplantations (s; n = 28). Cardiopulmonary bypass was required in 5 patients, whereas 56 required arteriovenous extracorporeal membrane oxygenation, including extended use in 3 before and 10 after LT. The main morbidities and complications after LT were sepsis (n = 11), primary graft dysfunction (PGD, n = 10), anastomotic stenosis (n = 10), acute rejection episodes (n = 25), and bronchiolitis obliterans syndrome (n = 15). In-hospital mortality was 18%, including sepsis (n = 10), PGD (n = 6), acute rejection episode (n = 1) and pulmonary infarction (n = 1). The mean survival time was 3.4 years. ConclusionsIn China, lung transplantation may offer a viable therapy for patients with various end-stage pulmonary conditions. The initiation of LT should focus on improving the survival rate by increased clinical practice.

Perioperative Management of Adult Surgical Patients on Extracorporeal Membrane Oxygenation Support

XTRACORPOREAL MECHANICAL support devices are used as an adjunct in the management of critically ill patients who are refractory to more conventional modes of therapy. Extracorporeal membrane oxygenation (ECMO) is one such device that has been used mainly in the management of patients in cardiogenic shock or respiratory failure who failed therapy on maximal ventilator settings and maximal pharmacologic support. ECMO has the advantage of being rapidly deployable, both at the bedside and in the operating room, and can be initiated without the need for general anesthesia. ECMO has been used as a bridging device to recovery or to more definitive therapy. In patients who are awaiting lung transplantation, ECMO has been used as a bridge to transplant when decompensation occurs and also as an adjunct in physical rehabilitation before transplant. The science and instrumentation of ECMO are direct outgrowths of the development of cardiopulmonary bypass (CPB) technology that reached its full potential in support of cardiac surgery in the latter half of the 20th century. This is a fascinating history in itself and has been reviewed thoughtfully at key points by physician-scientists directly involved in the process. 1-3 Over the last decade, the design and reliability of components of the ECMO circuit have improved markedly from earlier iterations, and clinical teams have gained experience with a multidisciplinary approach to the management of patients on ECMO. These advancements have led to more prolonged and widespread use of ECMO as an alternative for support in patients with otherwise nonsurvivable respiratory or cardiopulmonary failure. Outcomes also have improved from what is reported in the older medical literature. With the increase in the use of ECMO, anesthesiologists have become more involved in the perioperative management of these critically ill patients, and an understanding of the physiologic changes that occur in patients on ECMO is essential for perioperative management. In addition, a number of issues remain controversial, mainly regarding risk/benefit differentials in pediatric versus older age groups, end-stage versus acute disease, and the timing and duration of therapy. This review addresses the practical clinical problems during the perioperative management of adult patients on ECMO. TYPES OF ECMO Three major configurations of ECMO are available. Venovenous (VV) ECMO is used in the management of patients with refractory pulmonary failure and stable cardiovascular status. Venoarterial (VA) ECMO is used in patients with refractory cardiogenic shock or cardiorespiratory failure. The third configuration, arteriovenous (AV) ECMO, also known as the “artificial lung,” can be used in patients with acute lung injury presenting with stable cardiovascular status. In this review, the term “inflow cannula” refers to the cannula that carries blood from the patient into the ECMO system, and “outflow cannula” refers to the cannula that carries oxygenated blood from the ECMO system back to the patient. In VV ECMO, the inflow and outflow ECMO cannulae run in and out of the venous system in the patient. In VA ECMO, the inflow cannula is from the patient’s venous system, but the outflow cannula runs into the arterial system. Conversely, in AV ECMO, the inflow cannula is from the patient’s arterial system with the outflow cannula from the oxygenator running into the patient’s venous system. AV ECMO differs from VA and VV ECMO in that the AV ECMO circuit does not incorporate a pump to maintain blood flow in the circuit. Blood flow in this type of circuit is a function of systemic blood pressure, cardiovascular stability, the resistance of the membrane oxygenator, the size and length of the conducting circuit, and blood viscosity. Adequate blood pressure and cardiovascular stability are required to maintain blood flow in this form of circuit. Commonly used inflow cannulation sites during VV and VA ECMO are the femoral vein, the inferior vena cava, the superior vena cava, and the right atrium. Outflow during VV ECMO may be into any of these sites. In patients on VA ECMO, inflow usually is into the femoral artery, axillary artery, ascending aorta, or the pulmonary artery. Inflow during AV ECMO may