Combination Of Extracorporeal Membrane Oxygenation Research Articles

Outcomes of patients with COVID-19 requiring extracorporeal membrane oxygenation and continuous renal replacement therapy in the United States.

Coronavirus disease 2019 (COVID-19) infection is associated with significant morbidity and mortality. Some patients develop severe acute respiratory distress syndrome and kidney failure requiring the combination of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Retrospective cohort study of 127 consecutive patients requiring combined ECMO and CRRT support in intensive care units at an ECMO center in Marietta, GA, United States. Sixty and 67 patients with and without COVID-19, respectively, required ECMO-CRRT support. After adjusting for confounding variables, patients with COVID-19 had increased mortality at 30 days (hazard ratio [HR], 5.19; 95% confidence interval [CI], 2.51-10.7; P<0.001) and 90 days (HR, 6.23; 95% CI, 2.60-14.9; P<0.001). In this retrospective study, patients with COVID-19 who required ECMO-CRRT had increased mortality when compared to patients without COVID-19.

Heart transplantation in children and adults with Down syndrome: A single centre experience.

In recent years, rapid advances in cardiac surgery and changes in attitude towards patients with cognitive disability have led to these patients receiving cardiac transplantation. This is a retrospective report describing the experience of four patients with Down Syndrome who received heart transplantation in a single institution. Anthracycline-induced cardiomyopathy was the most common cause of heart failure in this group (3/4). Two patients were bridged to transplantation, one by using a combination of extra-corporeal membrane oxygenation and biventricular assist device and the other by using a durable implantable left ventricular assist device. All the four patients are alive with the longest surviving patient 17 years after transplantation. Against strong hypothetical predictions, we observed no propensity for the development of post-transplant infections or lymphoproliferative disorders. Down Syndrome should not be the sole contraindication to heart transplantation. The decision for transplantation should be on a case-by-case basis provided adequate social support is in place.

Kawasaki disease shock syndrome rescued by a combination of extracorporeal membrane oxygenation, steroids, and intravenous immunoglobulin

Kawasaki disease shock syndrome (KDSS) is defined as a sustained decrease in systolic blood pressure or signs of poor perfusion. Some children with KDSS are refractory to conventional therapy, such as intravenous immunoglobulin (IVIG). A 4-year-old boy with Kawasaki disease was referred to the emergency department. Despite the conventional therapy, his vital signs and cardiac function worsened. The boy promptly underwent extracorporeal membrane oxygenation (ECMO), which did not relieve the symptoms. Subsequently, he underwent methylprednisolone pulse therapy and the second cycle of IVIG therapy. Two days after the start of a combination of ECMO, steroids, and IVIG started, his clinical condition was stabilized, and finally, ECMO was removed. This case highlights the combination of ECMO, steroids, and IVIG as a treatment option for children with IVIG-resistant KDSS.

Case Series Report: Management of Anesthesia in Children Undergoing Complex Surgery of Tracheoesophageal Fistula after Ingestion of Button Batteries

Button battery ingestions in children increased in recent years and may lead to life-threatening complications, especially if the battery is impacted in the esophagus. The pH close to the negative pole of the battery can rise in a very alkalotic range (pH > 10) leading to severe tissue damage. Therefore, in this case series report, the clinical courses of four children with button battery ingestion leading to tracheoesophageal fistulas are presented. The diagnosis and removal of the button battery was delayed in all cases. The surgical reconstruction of the trachea was performed in intravenous anesthesia and with extended monitoring. The intraoperative oxygenation was maintained using a combination of extracorporeal membrane oxygenation (ECMO) and mechanical ventilation via an endobronchial tube. To prevent these life-threatening complications, the awareness of the parents and child care providers should be raised, and the manufacturers should redesign their products to secure the battery compartment. In children with suspected battery ingestions, the immediate localization and removal of the battery (< 2 h) is of highest importance. Local administration of honey or sucralfate can be considered in ingestions < 12 h but should not delay an endoscopic removal.

Combined extracorporeal membrane oxygenation and microaxial pump-when left ventricular preload is too low to unload in cardiogenic shock.

PurposeSevere cardiogenic shock is the major driver of mortality on cardiologic intensive care units. Novel therapeutic options like extracorporeal membrane oxygenation (ECMO) or the combination of ECMO and a percutaneous microaxial pump like Impella CP (ECMELLA) are promising Options. Here we want to focus on the question what happens when left ventricular preload is too low to unload in cardiogenic shock in patients with ECMELLA and this aspect is illustrated by transesophageal echocardiography.MethodsWe detail a case of a 43‐year‐old active smoker who was admitted for acute myocardial infarction causing severe cardiogenic shock and who was finally treated with ECMELLA. Transesophageal echocardiography is used to illustrate what happens when left ventricle (LV) preload is too low to unload.ResultsTransesophageal echocardiography demonstrates complete collapse of LV and LA as consequence of increased but still low flow rate of the coaxial pump.ConclusionNovel therapeutic options like ECMO and percutaneous microaxial pumps like Impella CP, 5.0 or the combination of both (ECMELLA), are promising options. Whether these approaches reduce mortality has to be evaluated in urgently needed randomized trials but results will not be available in the next few years.

The use of therapeutic plasma exchange for pediatric patients supported on extracorporeal membranous oxygenator therapy: A narrative review.

Therapeutic plasma exchange in children is increasingly recognized as a life-saving treatment and is challenged by some technical considerations. As extracorporeal membrane oxygenation has been used for nearly half a century for refractory reversible respiratory and/or cardiac failure in both pediatric and adult populations, it may serve as an extracorporeal platform for therapeutic plasma exchange. It is most commonly described in patients with sepsis with multiple organ failure or thrombocytopenia associated multi organ failure. Additional pathophysiological processes of inflammatory and immunological storms might benefit from the combination of extracorporeal membrane oxygenation and plasma exchange. This is a nonmethodological review of English-language reports of therapeutic plasma exchange performed in patients supported by extracorporeal membrane oxygenation, both pediatric and adult, searching six databases, MEDLINE, Clinical Key, GOOGLE SCHOLAR, CINAHL, Cochrane library, and EMBASE.

Abstract 13306: Impella Combined With Extracorporeal Membrane Oxygenation Synergistically Unloads the Left Ventricle and Reduces Infarct Size in a Model of Myocardial Infarction With Cardiogenic Shock

Introduction: Extracorporeal membrane oxygenation (ECMO) supports hemodynamics in cardiogenic shock (CS) at the expense of left ventricular (LV) overload. LV assist device (LVAD) also supports hemodynamics, whereas LVAD unloads LV. Therefore, the combination of ECMO and LVAD would augment hemodynamic support and unload LV. We hypothesized that the combination therapy in acute myocardial infarct (AMI) in CS could synergistically improve hemodynamics and unload LV, which, in turn, reduces infarct size. Methods: In protocol 1, we ligated coronary arteries and created AMI with CS in 5 mongrel dogs (15.1±0.3 kg). We transvascularly introduced Impella CP into LV. We kept the ECMO flow constant at 1.8L/min. We compared hemodynamics and the LV pressure-volume area (PVA, an index of LV oxygen consumption) under 3 conditions; Control, ECMO, and ECMO+Impella (ECPELLA) in each dog. In protocol 2 (n=15), we ligated coronary arteries for 180 min and then reperfused. We activated Impella CP and/or ECMO from 60 min after the coronary ligation to the end of the experiment. We allocated dogs into 3 groups, no support (Control), ECMO, and ECPELLA and compared infarct size at 180 min after reperfusion among 3 groups. Results: In protocol 1, both ECMO and ECPELLA increased arterial pressure compared to Control (Control: 63±9, ECMO: 88±10 and ECPELLA: 97±18 mmHg, p &lt; 0.05), and resolved the CS status. ECPELLA strikingly reduced PVA by 83% relative to Control (1500±326, 2038±357 and 258±182 mmHg*ml, p&lt;0.001). In protocol 2, ECPELLA markedly reduced the infarct size (15±8%) compared to Control (53±7%, p&lt;0.05) and ECMO (39±10%, p&lt;0.05). Conclusions: ECPELLA before reperfusion markedly improved hemodynamics, reduced PVA, and limited infarct size in a dog model of MI with CS. ECPELLA could prevent ECMO-induced LV overload and synergistically exert powerful anti-infarct effects in AMI with CS.

"Awake" Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant

The outcomes of patients bridged to lung transplant using extracorporeal membrane oxygenation (ECMO) have substantially improved in the last decade. Dual lumen cannula has revolutionized ECMO management by allowing patients to remain awake and ambulate while on ECMO support. The United Network for Organ Sharing (UNOS) database was queried for adult patients undergoing isolated lung transplantation between January 2010 and December 2018. The study population was classified based on ECMO or mechanical ventilation (MV) at the time of transplant and divided into 4 groups: 1) No ECMO&MV; 2) ECMO-only (ECMO without MV); 3) MV+ECMO (ECMO with MV); and 4) MV-only (no ECMO with MV). Survival comparisons and predictors of mortality were analyzed. A total of 18,055 lung transplantations were performed during the study period. 314 required ECMO-only, 480 required MV+ECMO, and 719 required MV-only. Survival was significantly worse for patients requiring MV+ECMO (HR 1.33, 95%CI 1.01-1.74, p=0.04) or MV-only (HR 1.63, 95%CI 1.27-2.09, p<0.001) compared to ECMO-only. There was no significant difference in survival between ECMO-only and No ECMO&MV (HR 1.02, 95%CI 0.82-1.27, p=0.88, Figure). Within the study cohort, recipient requiring MV at listing (OR 1.39, 95% CI 1.14-1.69, p=0.001), bilateral lung transplant (OR 0.58, 95%CI 0.53-0.64, p<0.001) and recipient dialysis (OR 3.31, 95%CI 2.02-5.44, p<0.001) were associated with mortality on multivariate analysis. ECMO-only (OR 0.87, 95%CI 0.68-1.13) was not a significant predictor of mortality. In subgroup analysis in ECMO cohort, MV+ECMO was associated with diabetes (p<0.001), infection requiring IV antibiotics (p=0.003), and cystic fibrosis/bronchiectasis (p<0.001). Awake ECMO is a feasible and safe option for bridge to transplant in eligible patients with end stage lung disease. The combination of ECMO and MV is associated with decrease post-transplant survival. Listing should be carefully considered in this particular clinical scenario.

Hybrid extracorporeal membrane oxygenation.

Veno-venous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) therapy is widely used in critically ill patients with refractory cardiogenic shock and cardiac arrest or suffering from severe respiratory failure. Besides traditional ECMO cannulation, changes in patients' conditions or the occurrence of specific complications (i.e., cerebral hypoxia or left ventricular dilation) may require modifications in cannulation strategies or the combination of ECMO with additional invasive or minimally invasive procedures, to improve organ function and ECMO efficiency. In this review, we described all these "hybrid" approaches, such as the addition of a third or fourth ECMO cannula to improve venous drainage and/or optimize systemic hemodynamics/oxygenation, or the implementation of surgical or percutaneous unloading of the left ventricle (LV), to reduce cardiac dilation and pulmonary edema. Although few data are still available about the effectiveness of such interventions, clinicians should be aware of these advances in ECMO management to improve the management of more complex cases.

Successful rescue combination of extracorporeal membrane oxygenation, high-frequency oscillatory ventilation and prone positioning for the management of severe methicillin-resistant Staphylococcus aureus pneumonia complicated by pneumothorax: a case report and literature review

BackgroundTo describe the experience of combination therapy with extracorporeal membrane oxygenation(ECMO), high-frequency oscillatory ventilation(HFOV) and prone positioning in treating severe respiratory failure caused by community acquired methicillin resistant Staphylococcus aureus(CA-MRSA).Case presentationA 30-year-old female presented with fever and dyspnea for 3 days. She was diagnosed CA-MRSA pneumonia complicated by severe respiratory failure, pneumothorax and neutropenia. Venovenous ECMO was applied within 8 h of the pneumothorax diagnosis. For amelioration of ventilator-induced lung injury, HFOV and prone positioning were combined with ECMO. The patient’s condition improved considerably. ECMO was weaned on day 19, and she was discharged on day 48 with good lung recovery.ConclusionsTo the best of our knowledge, this was the first case in which ECMO was combined with HFOV and prone positioning to treat severe necrotic CA-MRSA pneumonia complicated with pneumothorax. This combination therapy may provide safe respiratory support, may minimize the risk of barotrauma, and provide better drainage of secretions in patients with necrotizing pneumonia.

The Use of GMP-Produced Bone Marrow-Derived Stem Cells in Combination with Extracorporeal Membrane Oxygenation in ARDS: An Animal Model

Acute respiratory distress syndrome (ARDS) is the result of a wide variety of disorders, which can be associated with different clinical disorders or systemic diseases directly affecting the lungs. Currently, the only existing therapy is limited to supportive care. In a 6 hour pilot study, we analyzed the use of the combination of both stem cell and extracorporeal membrane oxygenation (ECMO) strategies to prevent or treat severe lung injury. A total of 11 sheep were used. Five sheep received Escherichia coli endotoxin as a control group (group 1). Three sheep that received E. coli endotoxin were treated with veno-venous ECMO support in group 2. In group 3, 3 sheep received a dose of clinical grade good manufacturing practice (GMP)-produced MultiPotent Adult Progenitor cells (MAPC) intratracheally after the end of the infusion of E. coli endotoxin, followed by ECMO support. The respiratory parameters by means of blood gas results, measurements of lung injury, inflammatory responses, and integrity of the alveolar capillary barrier after the infusion of these cells were analyzed. Our data suggest that the combination of ECMO and stem cell therapy showed better histopathologic changes with less inflammation. We believe that the combination of stem cells with the ECMO treatment may be useful in future studies investigating the diagnosis, treatment, and prevention of ARDS.

Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill patients: a systematic review.

IntroductionExtracorporeal membrane oxygenation (ECMO) is used in critically ill patients presenting acute cardiac and/or pulmonary dysfunctions, who are at high risk of developing acute kidney injury and fluid overload. Continuous renal replacement therapy (CRRT) is commonly used in intensive care units (ICU) to provide renal replacement and fluid management. We conducted a review to assess the feasibility, efficacy and safety of the combination of ECMO and CRRT and to illustrate the indications and methodology of providing renal replacement therapy during the ECMO procedure.MethodWe searched for all published reports of a randomized controlled trial (RCT), quasi-RCT, or other comparative study design, conducted in patients undergoing ECMO plus CRRT. Two reviewers independently selected potential studies and extracted data. We used the modified Jadad scale and the Newcastle-Ottawa for quality assessment of RCTs and non-RCTs, respectively. Statistical analyses were performed using RevMan 5.2.ResultsWe identified 19 studies meeting the eligibility criteria (seven cohort, six case control, one historically controlled trial and five studies of technical aspects). There are three major methods for performing CRRT during ECMO: ‘independent CRRT access’, ‘introduction of a hemofiltration filter into the ECMO circuit (in-line hemofilter)’ and ‘introduction of a CRRT device into the ECMO circuit’. We conducted a review with limited data synthesis rather than a formal meta-analysis because there could be greater heterogeneity in a systematic review of non-randomized studies than that of randomized trials. For ECMO survivors receiving CRRT, overall fluid balance was less than that in non-CRRT survivors. There was a higher mortality and a longer ECMO duration when CRRT was added, which may reflect a relatively higher severity of illness in patients who received ECMO plus CRRT.ConclusionsThe combination of ECMO and CRRT in a variety of methods appears to be a safe and effective technique that improves fluid balance and electrolyte disturbances. Prospective studies would be beneficial in determining the potential of this technique to improve the outcome in critically ill patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0675-x) contains supplementary material, which is available to authorized users.

Short-term mechanical support and pharmacotherapy, a new strategy in cardiogenic shock?

Editorial comment on ‘Preventing LVAD implantation by early short-term mechanical support and prolonged inodilator therapy: a case series with acute refractory cardiogenic shock treated with veno-arterial ECMO and optimised medical strategy’ J.J. Brugts, O. Manintveld, A. Constantinescu, D. Donker, R. van Thiel, K. Nieman, L. Jewbali, F. Zijlstra, K. Caliskan In this issue of the Netherlands Heart Journal, Brugts et al. describe a series of cases with acute severe refractory cardiogenic shock [1]. All three patients had no relevant cardiac history and were initially referred for durable left ventricular assist device (LVAD) implantation and/or heart transplantation (HTx). Dilated cardiomyopathy was diagnosed in two patients (one with an unknown cause, one due to alcohol/toxicity), while parvo B10 viral myocarditis was confirmed by biopsy in the other patient. Veno-arterial extracorporal life support (VA-ECLS) was started because a high dose of positive inotropes and intra-aortic balloon pump (IABP) were insufficient. Low-dose beta blocker and ACE inhibition were initiated early and titrated in combination with phosphodiesterase inhibition (enoximone). In all three cases cardiac function recovered and the patients were successfully weaned from VA-ECLS without any signs of relapse in up to 3.5 years of follow-up. The authors conclude that the combination of extracorporeal membrane oxygenation (ECMO) and early introduction of heart failure medication under the umbrella of phosphodiesterase inhibition provided momentum to survive and prevent LVAD implantation. The introduction of extracorporal life support in the 1970s has defined the standard of care in so-called ‘crash and burn’ (INTERMACS 1) patients [2]. The clinical management of this patient category is still hampered by the high mortality rate but also by the lack of accurate guidelines to confirm the appropriate patients and timing for mechanical circulatory support [3]. The rise of durable LVADs has significantly improved survival in end-stage heart failure and has provided a successful bridge to transplantation [4]. However, results of durable LVADs as bridge to recovery are poor, with maximal sustained recovery rates of 20.5 % recorded by Birks in a large cohort of 92 patients with an aggressive supporting pharmacological regimen [5, 6]. Though infrequent, cardiac recovery is primarily seen in non-ischaemic cardiomyopathy with divided aetiology between myocarditis, peripartum cardiomyopathy and idiopathic, potentially reversible causes of heart failure [5–7]. Analysis on survival after implantation of a durable LVAD in different INTERMACS categories revealed dramatically high mortality rates in INTERMACS profiles 1 and 2, compared with less critically ill patients [8]. This finding gave rise to the current applied strategy of short-term mechanical circulatory support in ‘crash and burn’ patients [2]. Especially in potentially reversible causes of cardiogenic shock, temporary ECLS can be sufficient. When recovery does not meet explantation criteria a long-term device and/or heart transplantation is still indicated. Although the strategy of preventing LVAD implantation by early short-term mechanical support and prolonged inodilator therapy is described in the present case series as a novel approach, clinicians worldwide are already initially treating INTERMACS profile 1 patients with short-term mechanical support to prevent mortality. To promote reversal of heart failure, different combinations of pharmacological strategies have been investigated. For example, sustained recovery was seen in the majority of a small group of patients with acute and severe non-ischaemic cardiomyopathy without active myocarditis treated with a strict pharmacological treatment consisting of the β2-agonist clenbuterol [9]. From the investigated combination of heart failure medication with enoximone, no conclusion can be drawn. Widely, the benefit of beta blockers in unstable severe heart failure is lacking evidence, due to routine exclusions in studies, and one should be extremely cautious in case of right ventricular failure [3, 10]. A recent retrospective study on early heart failure pharmacotherapy in ongoing cardiogenic shock compared patients who did and did not receive heart failure therapy within 24 h of admission. In comparison with no therapy, administration of β-blocker was significantly associated with an increased 30-day mortality and longer median duration of shock [11]. Rather than preventing the pathway of long-term LVAD support, the reported cases elegantly describe recovery of heart failure with state of the art treatment with ECLS in potentially reversible causes of cardiogenic shock. The additive value of the pharmacological regimen cannot be concluded from this series without a control group. Controlled studies are necessary to examine the value (or harm) of early introduction of heart failure medication.

Renal function and survival in 200 patients undergoing ECMO therapy

Extracorporeal membrane oxygenation (ECMO) is increasingly used in the intensive care unit (ICU) setting to improve gas exchange in patients with acute respiratory distress syndrome as well as in patients pre- and post-heart and lung transplantation. In this clinical setting, acute kidney injury (AKI) is frequently observed. So far, it is unknown how AKI affects the survival of critically ill patients receiving ECMO support and whether veno-veno and veno-arterial ECMO have different effects on kidney function. This is a retrospective analysis of patients undergoing ECMO treatment in medical and surgical ICUs in a tertiary care centre. We evaluated all patients undergoing ECMO treatment at our centre between 1 January 2005 and 31 December 2010. Data from all 200 patients (83F/117M), median age 45 (17-83) years, were obtained by chart review. Follow-up data were obtained for up to 3 months. Three-month survival of all patients was 31%. Of the 200 patients undergoing ECMO treatment, 60% (120/200) required renal replacement therapy (RRT) for AKI. While patients without RRT showed a 3-month survival of 53%, the survival of patients with AKI requiring RRT was 17% (P = 0.001). Longer duration of RRT was associated with a higher mortality. AKI requiring RRT therapy in patients undergoing ECMO treatment increases mortality in ICU patients. Future studies have to clarify whether it is possible to identify patients who benefit from the combination of ECMO and RRT.

Should We Emergently Revascularize Occluded Coronaries for Cardiac Arrest?

Background— Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. Methods and Results— This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P =0.01), the intra-arrest PCI was higher (88% versus 70%; P =0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25–51] versus 54 minutes [34–74 minutes]; P =0.002). Conclusions— Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed.

674 Acute Renal Failure Does Not Predict Long-Term Outcome after Heart Transplantation

associated hypoxemia, different types of MS are considered. We evaluate the outcomes in this population and the influence of the type of MS used. Methods and Materials: 101 patients presented PGD requiring MS, between 01/2000-07/2011. Intra-aortic Balloon Pump (IABP) was used in 40 cases with mild-moderate ventricular dysfunction. Extracorporeal Membrane Oxygenation (ECMO) was used in 30 cases with severe ventricular dysfunction not infrequently with associated hypoxemia. Ventricular Assist Device (VAD) was used in 19 cases (18 RVAD,1 BiVAD). Combination of ECMO after VAD (or vice-versa) was used in 12 cases (combined MS). Results: No significant donor or recipients differences were noted among the groups, except for higher age and pre-transplant pacemaker/ICD in the VAD group (p 0.04 and 0.04). 30-day and 1-year survival were 98%, 79%, 50%, 25% and 90%, 53%, 43%, 8% in the IABP, VAD, ECMO and combined MS groups respectively. Patients undergoing VAD implantation requiring also ECMO support had higher risk of mortality than those not requiring ECMO pre or post VAD implant (p 0.002). Multivariate analysis showed ECMO (alone or with VAD) (HR:11.95,95%CI:4.3532.85,p 0.0001), preoperative cardiac surgery (HR:2.46,95%CI:1.135.36,p 0.023), and diabetes (HR:2.21,95%CI:0.99-5.01,p 0.050) as risk factors of 30-day mortality.

Combination of extracorporeal membrane oxygenation and high-frequency oscillatory ventilation saved a child with severe ARDS after pulmonary resection

We report a case in which a 2-year-old girl who underwent a right middle and lower lung lobectomy for congenital cystic adenomatoid malformation suffered massive bleeding and developed acute respiratory distress syndrome (ARDS) during the operation. She was ventilated with a high level of F(I)O(2) (0.75-1.0), PEEP (10-20cmH(2)O), and PIP (33-55cmH(2)O) to maintain SPO(2) (>90%). Following transfer to the ICU, continuous hemodialysis was introduced to reduce excessive blood volume. However, pulmonary oxygenation did not improve, and marked subcutaneous emphysema occurred on postoperative day 3 (POD 3). We introduced venovenous (V-V) extracorporeal membrane oxygenation (ECMO) to rest the lung, and V-V ECMO was changed to right and left atrial ECMO because of unsatisfactory oxygen support on POD 23. A CT scan showed almost the entire lung had collapsed, even though we had administered diuretics, steroids, nitric oxide, sivelestat, and surfactant for ARDS. We applied high-frequency oscillatory ventilation (HFOV) with a mean airway pressure of 20cmH(2)O, frequency of 9.2Hz, and amplitude of 38cmH(2)O on POD 45. The collapsed lung was then gradually recruited, and pulmonary oxygenation improved (P/F ratio=434). ECMO was successfully weaned on POD 88. The patient required a tracheostomy, but she was able to function without a ventilator on POD 142. Although HFOV has failed to show a mortality benefit in ARDS patients, the unique lung recruitment by HFOV can be a useful therapeutic option for severe ARDS patients in combination with sufficient lung rest produced by ECMO.

Eight-year follow-up after palliative embolization of a neonatal intracranial dural arteriovenous fistula with high-output heart failure: management strategies for symptomatic fistula growth and bilateral femoral occlusions in pediatric patients

The authors report the 8-year follow-up of a patient previously described in the literature who originally presented in high-output cardiac failure secondary to a complex neonatal intracranial dural arteriovenous fistula (DAVF). The earlier case report described palliative treatment with a combination of extracorporeal membrane oxygenation (ECMO) and endovascular embolization for life-threatening high-output cardiac failure secondary to a DAVF. Access was obtained using the ECMO cannula, and embolization was performed while the patient was connected to the ECMO machine. The patient made an excellent recovery following partial embolization of the fistula, but then presented again 7 years later with worsening headaches secondary to significant growth of the known residual portion of the fistula identified on CT angiography. The child also developed bilateral femoral artery (FA) occlusions secondary to multiple previous FA punctures. To achieve complete obliteration of the remaining fistula, the patient required a retroperitoneal approach to the iliac artery and percutaneous puncture of the internal jugular vein. Embolization was performed with a combination of platinum coils and ethylene vinyl alcohol copolymer liquid embolic agent. There were no complications, and the child remains neurologically normal, with no signs of permanent cardiovascular sequelae. In this case report, the authors discuss the long-term management of AVFs treated by endovascular strategies early in life. After neonatal access, sometimes the FAs occlude, requiring more invasive access strategies. The authors also discuss the follow-up method, intervals, and threshold for further treatment for these lesions, and present a review of the literature.

The Use of Extracorporeal Membrane Oxygenation, High-Frequency Oscillatory Ventilation, and Surfactant for the Management of Intraoperative Acute Pulmonary Hemorrhage in Tetralogy of Fallot

ACUTE MASSIVE PULMONARY HEMORRHAGE occurring intraoperatively during the repair or palliation of complex congenital cardiac defects is a rare entity and often is fatal. 1 Baden H.P. Li C.M. Hall D. et al. High frequency oscillatory ventilation in the management of infants with pulmonary hemorrhage after cardiac surgery. J Cardiothorac Vasc Anesth. 1995; 9: 578-580 Abstract Full Text PDF PubMed Scopus (6) Google Scholar The authors report their experience in successfully managing acute massive pulmonary hemorrhage that occurred after the creation of a central shunt on cardiopulmonary bypass (CPB) in a 2-month-old former premature infant with tetralogy of Fallot, hypoplastic main and branch pulmonary arteries, and an anomalous coronary artery across the right ventricular outflow tract. The authors used a combination of extracorporeal membrane oxygenation, high-frequency oscillatory ventilation (HFOV), and surfactant to achieve a successful result.

Effect of circulatory assist devices on stunned myocardium

We studied the effects of mechanical circulatory assist devices on left ventricular oxygen consumption, the integrals of systolic left venticular wall stress (SSI), and end-systolic elastance (Ees) in 8 sheep after 25 minutes of global ischemia. Extracorporeal membrane oxygenation at 35 mL/kg/min, intraaortic balloon counterpulsation, and an intraaortic double-balloon pump were studied alone or in combination. Left ventricular oxygen consumption, SSI, and Ees were measured before and during mechanical circulatory assistance. Left ventricular oxygen consumption was calculated from transit-time measurements of left main coronary artery blood flow and fiberoptic measurements of coronary sinus blood oxygen saturation. Three pairs of sonomicrometry crystals placed across three orthogonal ventricular axes were used to calculate instantaneous ventricular volumes and pressure-volume loops from which the SSI data were derived. The Ees was measured using a new single-beat aortic occlusive method. Extracorporeal membrane oxygenation alone increased SSI and did not change Ees in postischemic poorly contracting hearts. Intraaortic balloon counterpulsation alone significantly reduced SSI and increased Ees. The combination of extracorporeal membrane oxygenation and either the intraaortic balloon pump or the intraaortic double-balloon pump reduced SSI, increased Ees, and reduced left ventricular oxygen consumption. In postischemic dilated, poorly contracting hearts, the combination of extracorporeal membrane oxygenation and intraaortic balloon counterpulsation has important advantages over extracorporeal membrane oxygenation alone.