Central Venoarterial Extracorporeal Membrane Oxygenation Research Articles

SINGLE-CENTER EXPERIENCE OF HEART TRANSPLANTATION AT THE HEART CENTER OF ASTANA

Background. Chronic heart failure is a major global health issue. As a complication of most cardiovascular diseases, it affects 4% of the population. Heart transplantation is the gold standard in the treatment of patients with end-stage heart failure. Objective of the study was to evaluate early and long-term outcomes of heart transplants performed at the Heart Center University Medical Center (Heart Center) over a 10-year period. Materials and methods. Cross-sectional study was conducted from 2012 to 2022, 86 orthotopic heart transplants were performed at the Heart Center. The analysis of the obtained results was conducted retrospectively. Results. From August 2012 to December 2022, 114 patients were on the waiting list for heart transplantation. Of these, 86 (75.4%) patients underwent transplantation; 10 (8.7%) patients were excluded. Among the 86 patients, 49 (56.9%) had previously undergone cardiac surgery. Of these, 42 (48.8%) had a left ventricular assist device implanted earlier, 3 (3.4%) had a fully artificial heart, and 2 (2.5%) were on temporary mechanical support (central veno-arterial Extracorporeal membrane oxygenation). Hospital mortality was 8 (9.3%) recipients. In 2.7% of cases, the cause of death was an acute cerebrovascular accident on the second day post-surgery. Postoperative renal dysfunction was noted in 28 (32.5%) patients. An analysis of all performed heart transplantation cases showed a 30-day survival rate of 94%, a 1-year survival rate of 84.3%, and a 5-year survival rate of 64.7%. Conclusion. In the hospital period and the first 6 months after heart transplantation, infectious-septic complications were predominant, whereas in later periods, rejection reactions were more common.

Bloodless lung transplantation: Comparison between 2 central venoarterial extracorporeal membrane oxygenation anticoagulation strategies and their impact on lung transplant outcomes

ObjectiveTo report differences between 2 anticoagulation protocols during venoarterial extracorporeal membrane oxygenation (VA-ECMO) intraoperative support and their effects on outcomes after lung transplantation. MethodsWe performed a retrospective analysis of patients undergoing double-lung transplantation with intraoperative VA-ECMO from January 1, 2016, to December 30, 2023. Two distinct anticoagulation protocols were in place during this period. One included targeted activated clotting time >180 seconds at all times with protamine reversal after decannulation. The second included 75 units per kilogram of heparin at the time of cannulation with no redosing plus a tranexamic acid infusion after ECMO initiation. ResultsA total of 116 patients (46 low heparin, 70 standard) were included in the analysis. Cannulation strategies and ECMO circuit were equivalent between the groups. The low-dose heparin protocol group had a shorter surgical time (7.28 hours vs 8.53 hours, P < .001) and required significantly less intraoperative packed red blood cells (median 0 vs 4.37 units, P < .001), fresh-frozen plasma (median 0 vs 2 units, P < .001), platelets (median 0 vs 1 units, P < .001), cryoprecipitate (median 0 vs 0 units, P < .001), and total blood products (median 0 vs 9 units, P < .001) compared with the standard group. There were no differences in rates of deep vein thrombosis (P = .13), airway dehiscence (P > .99), pneumonia (P = .38), or acute kidney injury requiring renal-replacement therapy (P = .59). There was no difference in rates of severe grade 3 primary graft dysfunction at 72 hours after transplant (P = .42). ConclusionsOur low-dose heparin VA-ECMO protocol for intraoperative support during lung transplantation led to a significant reduction of blood product use. Although this did not translate to a reduced rates of grade 3 primary graft dysfunction, the low-dose heparin protocol was associated with similar postoperative outcomes.

Potential Impact of Direct Versus Indirect Central Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Cannulation in Refractory Postcardiotomy Cardiogenic Shock.

Background Central venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a commonly employed strategy to support patients in refractory postcardiotomy cardiogenic shock (RPCS). This support can be provided using either indirect central ECMO (icECMO) with a closed thorax or direct central ECMO (dcECMO) with an open thorax. Methods This single-center retrospective analysis included 60 patients undergoing central VA-ECMO for RPCS from January 2019 to December 2020. The primary endpoint of this study is to compare 30-day survival outcomes between the icECMO and dcECMO approaches in RPCS patients. Secondary endpoints include the evaluation of adverse events and the identification of predictors that influence 30-day mortality. Results The study included 60 patients, 25 received icECMO and 35 treated with dcECMO due to RPCS. The icECMO group demonstrated significantly better 30-day survival rates (icECMO; 10 [40%] vs. dcECMO; 5 [14.3%], log-rank test; p=0.042). Despite comparable ECMO flow rate and ECMO RPM (rotations per minute) in the first day between the study groups ([icECMO; 4.5 l/min vs. dcECMO; 4.6 l/min, p=0.124], [icECMO; 3510 rpm vs. dcECMO; 3800 rpm, p=0.115], respectively), lactate levels were significantly higher in the dcECMO group on the 1st and 3rd post-extracorporeal life support (ECLS) days (p=0.006 and p=0.008, respectively). Gastrointestinal ischemia was more common in the dcECMO group (p=0.036). Successful ECMO weaning was more frequent in the icECMO group (56% vs. 22.9%, p=0.014). Multivariable logistic regression identified arterial lactate on the first day with a cutoff 4 mmol/las an independent risk factor for 30-day mortality with Exp(B) of 8.9 (p=0.007). Conclusions Our findings suggest a potential survival advantage with the icECMO technique in patients undergoing central ECMO cannulation after RPCS. However, larger prospective studies are essential to confirm this observation.

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.

A Rare Case of Symmetrical Peripheral Gangrene in Central Venoarterial Extracorporeal Membrane Oxygenator in a Pediatric Patient, an Unusual Complication of Extracorporeal Membrane Oxygenation

Symmetrical peripheral gangrene is an unusual complication of extracorporeal membrane oxygenation (ECMO) which can arise due to low cardiac output state, high inotropic support, inadequate anticoagulation, disseminated intravascular coagulation, and sepsis. In symmetrical peripheral gangrene, there is no evidence of large vessel occlusion or vasculitis. It can be due to the absence of pulsatile flow in the peripheral arteries that result in stasis and microthrombi formation which causes occlusion of small arterioles. A 10-month-old male child who underwent anomalous left coronary artery from pulmonary artery repair and required central venoarterial ECMO support post-surgery due to severe myocardial dysfunction developed symmetrical peripheral ischemia with gangrenous changes in the right-hand fingers while on extracorporeal membrane oxygenation (ECMO). The limb ischemic changes improved to normal after the child convalesced from heart failure. We describe these changes and the management here.

Harlequin effect and central veno-arterial extracorporeal life support.

"Harlequin effect" may be observed in the watershed region of a patient with pulmonary dysfunction, receiving peripheral veno-arterial extracorporeal membrane oxygenation via the femoral vessels. In such cases, retrograde oxygenated blood from the peripheral inflow cannula converges with the antegrade deoxygenated blood ejected from the left ventricle. This occurs when the left ventricle is ejecting significantly but the recovery of pulmonary function lags behind. Herein, we describe the occurrence of "Harlequin effect" in the setting of central veno-arterial extracorporeal membrane oxygenation that ensues due to the persistence of right ventricular dysfunction in the presence of an interatrial communication. This results in right to left shunting at the atrial level while weaning the patient from extracorporeal life support.

Sliding tracheoplasty of complete tracheal cartilage rings in children

IntroductionComplete tracheal rings are a rare malformation that occurs in 1 out of 100,000 live births. It is rare, isolated tracheal or tracheobronchial anomaly developed due to abnormal cartilage growth with formation of complete ring and often resulting in airway stenosis. Slide tracheoplasty, as it was originally described by Tsang et al. and popularized by Grillo et al., overlaps stenotic segments of trachea, shortening trachea itself, thus, doubling the circumference and diameter of the stenotic area. Materials and methodsWe have performed slide tracheoplasty in 12 children during the period of 2019–2021 in thoracic surgery department of our center. Median age was 15 ± 21,1 months (2 months-6 years),median weight – 8,04 ± 4,75 kg (3–20,7 kg),tracheal lumen varied from 2.5 to 3.0 mm, stenosis length – from 40 to 70% of the trachea length. ResultsSlide tracheoplasty was performed using central veno-arterial extracorporeal membrane oxygenation in 7 cases and using cardiopulmonary bypass in 5 cases. Concomitant heart disease was revealed in 5 children (pulmonary artery sling in 3 cases, ventricular septal defects – 1, aberrant subclavian artery −1). 5 children underwent one-stage correction of VSD: plastic VSD –1; left pulmonary artery reimplantation – 3; subclavian artery reimplantation – 1. All patients were on mechanical ventilation for 4,3 ± 2,78 days at postoperative period. Patients were discharged 16,3 ± 5,14 days after surgery. Satisfactory result of treatment in the form of respiratory failure relief was achieved in 10 patients. It was possible to increase the trachea lumen from 1.5 to 2 times in all cases. There were 2 (16,6%) fatal cases due to sepsis and multi-organ failure development. ConclusionsChildren with complete tracheal rings are very complicated patients with various comorbidities. Despite the advances in medicine, sometimes it is impossible to save lives of these children. The use of extracorporeal circulation (ECMO and bypass) allows us to safely perform reconstructive surgery on the trachea and save the child from respiratory failure manifestations. If needed, simultaneous correction of heart and tracheal defects is possible. Slide tracheoplasty allows to increase trachea lumen at least in 1.5–2 times. Mechanical ventilation is an unfavorable predictive factor for the outcomes of congenital tracheal stenosis management. Level of evidenceIII.

Concomitant Intra-Aortic Balloon Pumping Significantly Reduces Left Ventricular Pressure during Central Veno-Arterial Extracorporeal Membrane Oxygenation-Results from a Large Animal Model.

(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.

119 Axillary Intra-Aortic Balloon Pump, Biventricular Assist Device Implantation and Subsequent Orthotopic Heart Transplantation in a Patient with Sickle Cell Trait

Abstract A 38-year-old Caucasian male presented to a local hospital with breathlessness. After thorough investigation, transthoracic echocardiography demonstrated dilated cardiomyopathy. He continued to deteriorate and developed florid pulmonary oedema, necessitating transfer to our centre. Routine work-up for cardiac transplantation found him to be a carrier of the HbS sickle cell trait, with an HbS concentration of 34.4%. Due to uncertainty of candidacy and further deterioration, axillary-IABP supported his bridge-to-decision. An IABP was inserted under fluoroscopic guidance via the right axillary artery using Seldinger technique. He continued to deteriorate requiring implantation of a BiVAD. He developed cardiac tamponade 23 days after BiVAD implantation demanding surgical evacuation. His condition improved with recovery of renal and liver function and resolution of pulmonary oedema. As there was no evidence of myocardial recovery, he was placed on the super-urgent heart transplant (HTX) list. After 45 days of BiVAD support, he underwent orthotopic HTX. The donor heart was from a 31-year-old male transported on cold storage. The patient remained normothermic throughout and diastolic arrest was achieved with cold blood cardioplegia delivered via the aortic root. Upon completion of anastomoses, bleeding from the posterior aortic wall occurred, requiring further aortic cross-clamping, cold-blood cardioplegia and administration of multiple blood products. Subsequently, the right ventricle distended, and the septum became dyskinetic. Central veno-arterial extracorporeal membrane oxygenation was initiated uneventfully. VA-ECMO was weaned on the 5th-postoperative day, and he was discharged from the CTCCU six days later, he returned home 28 days after HTX. He maintained recovery and remains alive and well 34 months after discharge.

Transatrial balloon atrial septostomy to facilitate weaning off venoarterial ECMO after pulmonary endarterectomy.

Atrial septostomy has been the last resort in the management of patients with the right ventricular failure related to pulmonary hypertension before lung transplantation. In this paper, we present a simple and safe technique (transatrial approach) for balloon atrial septostomy in a patient who required central venoarterial extracorporeal membrane oxygenation after pulmonary endarterectomy.

Central venoarterial extracorporeal membrane oxygenation as a bridge to recovery after pulmonary endarterectomy in patients with decompensated right heart failure.

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) and decompensated right heart failure (DRHF) have worse outcomes after pulmonary endarterectomy (PEA). We reviewed the role of central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to recovery after PEA in these patients. Of 388 consecutive patients undergoing PEA, 40 (10.3%) were admitted with DRHF before PEA. This group was compared to the remaining 348 patients undergoing PEA (elective group). We also compared 2 periods: 2005-2013 (n=120) and 2014-2019 (n=268) after which early central VA-ECMO was introduced as a strategy to manage difficulty weaning from cardiopulmonary bypass (CPB). The proportion of patients with DRHF remained similar between the first and second period (13% vs 9%, p=.2). The number of VA-ECMO bridge to recovery increased from 0.8% in 2005-2013 to 6.3% in 2014-2019 (p=.02). In the second period, 29% of DRHF patients were transitioned intraoperatively from CPB to central VA-ECMO for a median duration of 3 (2-7) days. After the introduction of central VA-ECMO as a bridge to recovery, the hospital mortality in patients with DRHF dropped from 31% in 2005-2013 to 4% in 2014-2019 (p=.03). In the long-term, the functional recovery and survival after discharged from hospital was similar between the DRHF group and the elective group. However, at 5 years, DRHF patients more frequently required PH targeted medical therapy (45% vs 20% in the elective group, p=.002). Central VA-ECMO as a bridge to recovery is an important treatment strategy that can decrease hospital mortality in patients with DRHF and lead to excellent long-term outcome.

A Novel Approach to a Complex Problem

We congratulate Patel and colleagues1 on their case report in this issue of The Annals of Thoracic Surgery, which details a novel approach of central extracorporeal membrane oxygenation (ECMO) support via a minimally invasive approach as a bridge to heart-lung transplantation. Prior to being evaluated as a candidate for heart-lung transplantation, their patient had been urgently placed on peripheral venoarterial (VA) ECMO. To improve flow, minimize pulmonary congestion, and facilitate prehab, the authors converted the patient to central VA ECMO with pulmonary artery (PA) drainage via a minimally invasive (upper partial sternotomy) approach.

Central VA-ECMO Support without Full Anticoagulation is Feasible During Lung Transplant

<h3>Purpose</h3> Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is increasingly used instead of cardiopulmonary bypass (CPB) during lung transplant for mechanical circulatory support. In this study, we analyzed the feasibility of central VA-ECMO without full anticoagulation during lung transplantation. We also analyzed the incidence of morbidity including ischemic and thrombotic complications, stroke, and postoperative outcomes. <h3>Methods</h3> This is a retrospective review of an institutional lung transplant database. We included consecutive patients from March 2018 through January 2021. Patients were stratified into two cohorts: those undergoing central VA-ECMO during lung transplant and those undergoing traditional cardiopulmonary bypass. Patients undergoing VA-ECMO did not receive systemic anticoagulation at the time of surgery. 109 total patients were included in the study. <h3>Results</h3> 57 patients underwent central VA-ECMO during lung transplant while 52 underwent traditional cardiopulmonary bypass. The VA-ECMO patients had longer operative time and ischemic time then non VA-ECMO patients (7.9 ± 1.4 vs 6.4 ± 2.0, p<0.001, 5.3 ± 1.1 vs 4.2 ± 2.0, p<0.001). However, there was no significant difference in all of blood transfusion between two groups. Post-lung transplant complications between the VA-ECMO and non-VA-ECMO patients were similar, with the exception of AKI which was higher in VA-ECMO patients (52.2% vs 25.0%, p=0.01). Intensive care unit stay and overall hospital stay was not significantly different between the two groups. <h3>Conclusion</h3> These findings suggest that central VA-ECMO without anticoagulation is a safe alternative to traditional cardiopulmonary bypass during lung transplantation. While use of VA-ECMO increased operative time, it did not result in increased rate of blood transfusions or lengthen overall hospital stay. We believe this approach could improve outcomes associated with mechanical life support for lung transplant.

Cardiac tamponade in a patient supported by veno-arterial extracorporeal membrane oxygenation.

Cardiac tamponade occurring in a patient supported on central veno-arterial extracorporeal membrane oxygenation is depicted in a transesophageal echocardiography image and associated rendering. Prompt recognition of tamponade, which can be assisted with echocardiography, and emergent evacuation is critical to restoring cardiovascular stability.

Brazilian initial experience with lung transplantation due to irreversible lung fibrosis post-COVID-19 in a national reference center: a cohort study.

Lung transplantation (LTx) has been discussed as an option for treating irreversible lung fibrosis post-coronavirus disease 2019 (COVID-19), in selected cases. To report on the initial experience and management of end-stage lung disease due to COVID-19 at a national center reference in Brazil. Cohort study conducted at a national reference center for lung transplantation. Medical charts were reviewed regarding patients' demographics and pre-COVID-19 characteristics, post-LTx due to COVID-19. Between March 2020 and September 2021, there were 33 cases of LTx. During this period, we evaluated 11 cases of severe COVID-19-related acute respiratory distress syndrome (ARDS) that were potentially candidates for LTx. Among these, LTx was only indicated for three patients (9.1%). All of these patients were on venovenous extracorporeal membrane oxygenation (ECMO), and the procedure that they underwent was central venoarterial ECMO. All three patients were still alive after the first 30 postoperative days. However, patient #1 and patient #2 subsequently died due to fungal sepsis on the 47th and 52nd postoperative days, respectively. Patient #3 was discharged on the 30th postoperative day. LTx is feasible among these complex patients. Survival over the first 30 days was 100%, and this favors surgical feasibility. Nonetheless, these were critically ill patients.

Vascular complications based on mode of extracorporeal membrane oxygenation

BackgroundVascular complications remain a prevalent and devastating complication of extracorporeal membrane oxygenation (ECMO). Risks for vascular complications have risen as the volume and medical complexity of ECMO cases has rapidly increased in recent years. This study assesses occurrence and clinical impact of vascular complications across all ECMO modes and cannulation methods in a high-volume academic center. MethodsA retrospective single-institution review was performed of all ECMO cannulations for central or peripheral venovenous (VV) or venoarterial (VA) ECMO in 2019-2020. Patients who expired during cannulation were excluded. Primary outcomes of vascular consultation rates at or after ECMO placement, limb loss, and mortality were assessed during index hospitalization. ResultsA total of 229 patients were identified during the 2-year study period. VA ECMO was used in the majority of patients (n = 137, 60%), with 83% (N = 114) undergoing peripheral cannulation. Vascular surgery was consulted in 54 (23.6%) patients. Complication rates ranged from 33.9% in peripheral VA cannulation to 7% in jugular VV cannulation. Overall, 65% of vascular consults required operative intervention; interventions were highest in peripheral VA ECMO (n = 30 of 114, 26.3%). Across all ECMO types, acute limb ischemia (ALI) was the most common complication (n = 38, 16.5%), with rates ranging from 26.1% in central VA ECMO to 4.8% in jugular VV ECMO. Distal antegrade perfusion catheters (DPCs) were employed in n = 68 of 114 (59.6%) of all peripheral VA ECMO cases. Prophylactic DPCs were found to be incorrectly placed in 10.2% (n = 7 of 68) of cases, which obscured the ability to fully evaluate the effect of prophylactic DPCs on reducing rates of ALI. Major amputation (Below Knee Amputation/Above Knee Amputation) occurred in six peripheral VA patients (5.3%), two central VA patients (8.65), and two femoral-femoral VV patients (4%). Patients with ALI experienced significantly lower rates of in-hospital survival in Kaplan-Meier analysis (32.5% vs 54%, log-rank = 0.023). ConclusionsThis study highlights the prevalence of vascular complications, and their associated mortality impact, across all modes of ECMO and additionally identifies several areas for institutional performance improvement. ALI was the most common complication across all cohorts and was associated with decreased in-hospital survival. The impact of DPC on ALI was difficult to elucidate due to nonstandardized placement patterns and selective use. In the care of these medically complex patients on multidisciplinary teams, review of outcomes and group discussions targeting areas for improvement are critical to success; in this study, findings resulted in the development of a lower extremity perfusion management protocol.

Concomitant use of peripheral veno-venous extracorporeal membrane oxygenation (VV-ECMO) and central veno-arterial ECMO during lung transplantation for coronavirus disease 2019 patients

To summarize the strategy of using extracorporeal membrane oxygenation (ECMO) support during lung transplantation from 2 coronavirus disease 2019 (COVID-19) with end-stage respiratory failure. Two COVID-19 with end-stage respiratory failure patients were admitted to Nanjing Medical University Affiliated Wuxi People's Hospital in March 2020. As the homoeostasis and vital signs could not be maintained in balance by conventional treatments, lung transplantations were performed. Here, detail information about combined application of peripheral veno-venous ECMO (VV-ECMO) and central veno-arterial ECMO (CVA-ECMO) during the operation will be discussed. Case 1: 59 years old, 172 cm height, 72 kg weight, who received mechanical ventilation for 22 days, tracheotomy tube for 17 days, and VV-ECMO support for 7 days. Case 2: 72 years old, 178 cm height, 71 kg weight, who received mechanical ventilation for 19 days, tracheotomy tube for 17 days, and VV-ECMO support for 18 days. As both of them have severe COVID-19-associated respiratory failure, and the recovery was determined to be unlikely, lung transplantations were performed. Severe pulmonary arterial hypertension (PAH) and cardiac insufficiency were found during the operation. Based on preoperative VV-ECMO, CVA-ECMO was added. The concomitant use of peripheral VV-ECMO and CVA-ECMO offered satisfied intraoperative oxygenation and cardiopulmonary status,the operations run smoothly, and the CVA-ECMO was successfully removed, no ECMO-related complications occurred. The combined use of VV-ECMO and CVA-ECMO is an optimal strategy in the end-stage ARDS patients with severe PAH and cardiac insufficiency, which can offer benefits on respiratory and cardiac functions simultaneously, and ensure surgery safety.

Surgical Treatment of Patients with Full Tracheal Rings: Our Experience.

Introduction: Complete tracheal rings are a rare pathology occurring in 1 out of 100,000 live births. It is rare isolated tracheal or tracheobronchial anomaly resulting from abnormal cartilage growth, forming a complete ring, and leading to airway stenosis. A sliding tracheoplasty, primarily described by Tsang et al. and later widely presented by Grillo et al., overlaps the tracheal stenosing segments and shortens the trachea itself, and thus increases the diameter and circumference of the stenosing area double up. Materials and Methods: We have performed four slide tracheoplasties in the period between February 2019 and December 2020 in children who underwent medical treatment in the department of thoracic surgery in our center. Median age was 10 ± 5.5 months (2 months-1 year 6 months). Median weight was 6.9 ± 1.9 kg (4.5-9 kg). Slide tracheoplasty was performed using central venoarterial extracorporeal membrane oxygenation in 3 cases and using cardiopulmonary bypass in 1 case. Results: Patients were on artificial lung ventilation for 2-6 days in the postoperative period. Patients were discharged 14-18 days after the surgery. There were no lethal outcomes in our study. Discussion: Long segment congenital tracheal stenosis is an often and serious life-threatening anatomical malformation that bounded the length of trachea >50%. There is no unique treatment strategy for patients with such pathology. Sliding tracheoplasty can be recommended for all, but not for the shortest segments of stenosis, as it creates permissible voltage fluctuations during tracheal anastomosis. Excellent results in management of such severe patients can be achieved only through the collaboration of multidisciplinary team of specialists sharing organized and consistent patient-oriented approach.

Fatal air embolism during gastrointestinal endoscopy in a 5 -year- old girl

Gastrointestinal endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) are generally considered safe procedures with very minimal complications. However, they can be associated with uncommon yet life-threatening complications such as air embolism. A 5-year-old female was referred to our hospital for the evaluation of a left upper quadrant mass. The patient underwent exploratory laparotomy, and a biopsy was obtained. Histopathology confirmed the diagnosis of ganglioneuroblastoma. The patient afterwards underwent laparotomy, and tumor excision resulted in an iatrogenic injury to the superior mesenteric artery, leading to ischemic enteritis requiring multiple small bowel resections resulting in short bowel syndrome and small bowel strictures; gastrointestinal endoscopy was needed for dilatation. Unfortunately, during endoscopy, the patient developed air embolism and went into cardiac arrest. Then an urgent central venoarterial extracorporeal membrane oxygenation (ECMO) was deployed, and the patient was shifted to the intensive care unit and died a few hours later. Air embolism is considered a very rare yet fatal complication of endoscopy. The exact mechanism behind air embolism will differ from one patient to another, making it challenging to identify it. It is important to anticipate such complication in high-risk patients, and all precautions must be taken when performing endoscopic procedures.

How I do it: Totally extrapericardial, ambulatory central venoarterial extracorporeal membrane oxygenation as a bridge to heart transplantation.

How I do it: Totally extrapericardial, ambulatory central venoarterial extracorporeal membrane oxygenation as a bridge to heart transplantation.